Section 5: Configuration of healthcare to manage CKD

The Renal NSF: Part 1

• Standard 1: Patient centred service

• Standard 2: Preparation and choice

• Standard 3: Elective Dialysis access surgery

• Standard 4: Dialysis• Standard 5:

Transplantation

The Renal NSF: Part 2

• Quality requirement 1: Prevention and early detection of chronic kidney disease (CKD)

• Quality requirement 2: Minimising the progression and consequences of CKD

• Quality requirement 3: Acute renal failure

• Quality requirement 4:End of life care

Delay progression & reduce CVS Risk

Prevent uraemic complications

Modify co morbidities Prepare for RRT

ACE inhibitors Malnutrition Cardiac disease Education

BP control Anaemia Vascular disease Informed choice of RRT/conservative

management

Glucose control Calcium Phosphate PTH

Drug interactions Timely access placement/

Transplant Listing

Smoking cessation Acidosis Neuropathy/

Retinopathy

Timely initiation of RRT

Management of CKD

CKD = chronic kidney disease; RRT = renal replacement therapy

Early Detection of CKDEarly Detection of CKD Think/Report eGFR

NEOERICA: percentage recording of creatinine

and prevalence of Stage 3–5 CKD by age

0

10

20

30

40

50

60

70

80

15–24 25–34 35–44 45–54 55–64 65–74 75–84 85+

Age groups

Patients (%)

Recorded serum creatinine Stage 3–5 CKD

Source of Late Referrals Lamiere - NDT 1999

0

10

20

30

40

50

60

70

GP Gen. Med Urology Endocrine Cardiology

DIA

BE

TO

LO

GIS

TS

CA

RD

IOL

OG

IST

S

GE

N. M

ED

ICIN

E

GE

N. P

RA

CT

ICE

NE

PH

RO

LO

GIS

TS

SILO MANAGEMENT

DIA

BE

TO

LO

GIS

TS

CA

RD

IOL

OG

IST

S

GE

N. M

ED

ICIN

E

GE

N. P

RA

CT

ICE

SILO MANAGEMENT

CHRONIC DISEASE

MANAGEMENT

INTEGRATED MANAGEMENT

GFR

CKD: An Overall Health Approach

Complications

CKD risk factor

reduction, screening for CKD

Diagnosisand treatment,

treatcomorbid conditions,

slow progression

Estimate progression,

treatcomplications,

prepare for replacement

Replacementby dialysis

and transplant

Screeningfor CKD

risk factors

Kidneyfailure

DamageIncreasedrisk

Normal DEATH

CKD Stage 1, 2,3

EducationBlood pressure

Smoking cessationLipid control

Medicines ManagementDiet adviceExercise

Psychosocial support

CKD Stage 4

AnaemiaAcidosis

Bone diseasePreparation/choice

CKD Stage 5

RRTPDHPTp

Glycaemic control

Complicationseyesfeet

kidney

RadiologySurgical interventions

Anti coagulationAnti arrhythmics

Medical treatment of CHF

+ DM + CHD

Cardiac Kidney Diabetes

QOF indicators for CKD 2009Register of patients over 18 with CKD 3-5 6

Percentage of patients on the CKD register whose notes have a record of BP reading in last 15 months

6 40-90%

Percentage of patients on the CKD register in whom the last BP reading, measured in the last 15 months was 140/85 or less

11 40-70%

Percentage of patients on the register with hypertension and proteinuria treated with an ACE-I or ARB (unless side-effects are recorded)

4 40-80%

Percentage of patients on the register whose notes have a record of urine ACR or PCR in the previous 15 months

6 40-80%