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

hughrayner@nhs.net

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

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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

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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

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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

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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%

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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

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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)

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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 hugh.rayner@heartofengland.nhs.uk 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

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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 hughrayner@nhs.net

50YearsofDialysis.com