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Population-wide
Chronic Kidney Disease Management Reducing the Incidence
of Kidney Failure
Dr Hugh Rayner MD FRCP DipMedEd Consultant Nephrologist Heart of England NHS Foundation Trust
Birmingham
Pathology and renal services to c.900,000
Improving CKD outcomes
CKD 3 4 5 Dialysis
50 60 70 Age 40
Age 70 80 90
Before:
Improving CKD outcomes
CKD 3 4 5 Dialysis
50 60
CKD 3 4 5 Trans-plant
Age 70 80 90
After:
70 Age 40
Age 70 80 90
70 Age 40 50 60
Before:
CKD management program (2003-6)
Start RRT
Slow progression
Identify patients at
high risk
Primary care
Self care
How well are your kidneys
working now?
Reviewing U&E results
Date Creatinine eGFR 15.01.2014 117 60.3 19.11.2013 91 81.4 15.08.2013 105 68.7 07.06.2013 113 63.0 13.05.2013 94 78.5 04.02.2013 106 68.1
0
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140
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46 year old man, type I diabetes with nephropathy
eGFR ml/min/1.73m2
“Dear Mr Bloggs,
It was good to see you in clinic.
I was sorry to tell you that your kidney function is still going down...”
Yours sincerely
Support self-care
0
10
20
30
40
50
60
70
80
90
1999 2000 2001 2002 2003 2004 2005
eGFR ml/min/1.73m2
Write letters
directly to
patients
Share the
eGFR graph
Most people with diabetes do not develop kidney failure
Prevalence of dialysis or transplantation
in type 2 diabetes:
2003-4 = 0.26%
2009-10 = 0.56%
England National Diabetes Audit
Where’s Wally?
I’ve got diabetes,
high blood
pressure, protein
in my urine and
my kidney
function is
slowly getting
worse…
Risk filters
Secondary care
Falling eGFR
Reduced eGFR or
Heavy proteinuria
Start RRT
Slow progression
Identify patients at
high risk
Primary care
Self care
Nephrology CKD register
Patient Administration System
Pathology laboratory
Proton©
CKD Register
Patient attends nephrology or diabetes clinic
Blood test results
Weekly extracts listing patients with: • eGFR <15, for multidisciplinary pre-ESRD team review • diabetes + age<65 + eGFR<50 • diabetes + age>65 + eGFR<40
for eGFR graph review
Sudden deterioration in eGFR
eGFR
Gradual deterioration in eGFR
eGFR
0
50
100
150
200
250
300
350
400
2000 2002 2004 2006 2008 2010 2012
Follow-upvisits
First visits
Attendances at the diabetes-kidney clinic
Preserving kidney function in diabetic nephropathy
BP controlled
0
10
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30
40
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60
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1801
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3
19
94
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00
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01
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20
14
Incident RRTrate per millionpopulationaged over 14years
Numberstarting RRT
Patients starting RRT at Heart of England Foundation Trust
GP CKD QOF payments
Pre-ESRD team
eGFR reporting
Primary care education
Diabetes eGFR surveillance
Letters to patients
GP HT and diabetes QOF payments
Lowest rate of late presentation for chronic dialysis
Percentage of patients presenting <90 days prior to starting RRT, 2012/2013
HEFT % E, W & NI % 2009-10 9.9 20.6 2010-11 9.1 20.1 2011-12 7.4 19.5 2012-13 5.7 18.6
5.7%
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
Engl
and
B H
eart
Po
rts
Stev
ng
Car
lis
Sun
d
Du
dle
y
No
rwic
h
Bra
dfd
Do
nc
Leed
s
Do
rse
t
No
ttm
Pre
stn
She
ff
Glo
uc
De
rby
Yo
rk
Sth
en
d
Oxf
ord
Exe
ter
Co
vnt
Ke
nt
New
c
Bri
sto
l
Tru
ro
Leic
Co
lch
r
Shre
w
L K
ings
Car
sh
L W
est
Mid
dlb
r
Bas
ldn
Liv
Ro
y
M R
I
Red
ng
Wo
lve
Hu
ll
Liv
Ain
Cam
b
Bri
ghtn
Ch
elm
s
L R
free
Sto
ke
B Q
EH
Wir
ral
Ipsw
i
N Ir
elan
d
We
st N
I
An
trim
Uls
ter
New
ry
Be
lfas
t
Wal
es
Wre
xm
Car
dff
Ban
gor
Clw
yd
Swan
se
Engl
and
N Ir
elan
d
Wal
es
E, W
& N
I
Highest rate of early presentation for chronic dialysis
Percentage of patients presenting > one year prior to starting RRT, 2012/2013 UK Renal Registry Report 2014 90.1%
Best vascular access performance in the West Midlands
50%
55%
60%
65%
70%
75%
80%
85%
90%
95%
100%
HEFT UHNM SaTH RWH Dudley UHCW UHB
% of haemodialysis patients using an AV-fistula
April
May
June
July
August
September
October
November
December
January
2014/15
Survival of incident patients
UK Renal Registry Report 2013
Heart of England Kidney Function Monitor
Patient ZZC00261281
Date of Birth 17-Aug-1938 Sex M
Requesting
Clinician
Dr K Arora Location Perry Park 291 Walsall Rd
Date/Time of
Test
11-Apr-2012 04:13 Estimated
GFR
35 (ml/min)
0
10
20
30
40
50
60
70
80
90
100
01/01/2008 01/01/2009 01/01/2010 01/01/2011 01/01/2012
Est GFR (ml/min) GFR if Afro Caribbean Marked as Inform Clinician Marked as Urgent
Other Tests From The Last 5 Years
Test Highest Date Latest Date
HbA1c 7.6 % 27/02/2012 7.6 % 27/02/2012
Serum K 5.1 mmol/l 11/04/2012 5.1 mmol/l 11/04/2012
Serum Na 144 mmol/l 15/09/2008 134 mmol/l 11/04/2012
Serum Urea 12.4 mmol/l 11/04/2012 12.4 mmol/l 11/04/2012
Urine Protein 0.27 g/l 15/09/2010 0.07 g/l 27/02/2012
Urine albumin:creatinine
ratio
30.5 mg/mmol 15/09/2010 1.7 mg/mmol 27/02/2012
Diabetic Status on Renal Database Not Diabetic
Dear Dr Arora,
This results for this patient have reviewed as part of our departments system for monitoring chronic kidney disease
using cumulative graphs of eGFR. Based on our criteria, agreed with the renal medicine department, this patient has
been identified as at increased risk of progression to end-stage kidney disease.
If you requirefurther advice or information for the management of this patient please contact Dr Hugh Rayner at
Birmingham Heartlands Hospital.
Email [email protected] for a copy of 'CKD Made Easy'.
Please quote this patient's NHS number.
Kennedy DM, Chatha K, Rayner HC
Laboratory database population surveillance
to improve detection of progressive chronic
kidney disease.
Journal of Renal Care 2013; 39 Suppl 2:23-9
“CKD Made Easy
– a guide for general practice”
Google: ‘CKD Made Easy’
Since 2012:
Laboratory
surveillance and
selective graphical
reports
GP feedback (n=36)
• 30% usually looked at only the last few results
• 74% found the graphical eGFR report useful
• 41% had changed patient management in response to the report
• Average ease of use of the graphs = 8 out of 10 (10 = easiest)
GP feedback
“I would be grateful for your advice regarding the above 91 year old lady.
My query is in regards to her deteriorating eGFR which has been made clear by a graph that had been sent to me.”
UK prevalent population
UK
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Prevalent population on RRT UK Heart of England Trust
0
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500
1997 1999 2001 2003 2005 2007 2009 2011 2013 2015
Totaldialysis(HD + PD)
Transplant
HEFT prevalent population with ESRD
Summary of the benefits
Clinical
• Fewer patients reaching end-stage kidney failure
Financial • Cost of dialysis program stabilised
Environmental • Fewer patients attending hospital clinics
Social • Access to nephrology based upon health need regardless
of age, ethnicity and GP expertise in CKD
• Informed and shared decisions through better understanding of CKD by use of eGFR graphs
• Consultants in control of their workload
Thank you to my wonderful
colleagues Steve Smith
Mark Temple
Mark Thomas
Indy Dasgupta
Jyoti Baharani
Vijay Suresh
Does Community-Wide Chronic Kidney Disease Management Improve Patient Outcomes?
Nephrology Dialysis Transplantation March 2014 [email protected]
50YearsofDialysis.com
