OneLondon

Diabetic Kidney Disease Risk Stratification Pathway

For Winter 2020/21 and during the COVID-19 pandemic

Linda Tarm, Sarah Newall, Dr. Emmanuel Lamptey, Dr. Stephen Thomas, Dr. Neel Basudev

This guide should be used in combination with clinical judgement, and alongside existing guidelines, standards and/or clinical frameworks

Contents page

Communications and FAQ’s…………………………………………………………..…3

Risk Stratification Pathway………………………………………………………………5

Step-by-step guide for GP practices using EMIS………………………………..…..6

Stakeholder’s………….……………………………………………………………………7

References………………………………………………………………………………...8

What is the OneLondon Diabetic Kidney Disease Risk Stratification Pathway?

The OneLondon Diabetic Kidney Disease (DKD) Risk Stratification Pathway is a clinical care pathway that identifies people with diabetes who have rapidly progressing DKD and those at high risk of DKD progression.

The pathway outlines criteria for identifying and risk stratifying patients with DKD and guides primary care clinicians to appropriate interventions in order to prevent or delay DKD progression. It should be used in combination with clinical judgement, and alongside existing guidelines, standards and/or clinical frameworks. Also, individual practices should delegate tasks based on appropriate skill level of practice staff.

What is the purpose of the pathway?

The most common cause of chronic kidney disease (CKD) and end-stage renal failure (ESRF) is diabetes (Renal Association, 2017). DKD significantly increases the risk of morbidity and is strongly associated with adverse renal and cardiovascular outcomes (Winocour, 2017). Additionally, the economic burden is considerable. Current modelling predicts that by 2023, London will have an extra 600 dialysis patients at an annual cost of ~£14 million. This estimated cost is only for the dialysis process and does not include other associated services such as patient transport. Therefore, the true costs to the whole healthcare system would be higher (NHS England London Specialised Commissioning modelling based on UK Renal Registry data and Kerr et al. 2012).

Hence, the need to easily identify and treat DKD early is crucial as it may stop or delay the progression of DKD (NICE, 2014). However, practice in primary care varies widely, confirmed by a nationwide audit showing that only 54% of people with diabetes have the relevant annual urine tests (Nitsch et al, 2017).

In addition, anticipated winter pressures in the NHS and a second wave of COVID-19 means that capacity in many GP surgeries will be reduced. Hence, this pathway is timely and important as it helps primary care clinicians identify priority patients with DKD for immediate intervention (supported by clinical judgement) so that care can be managed safely during this period.

For people with diabetes, there are modifiable factors that are associated with a greater risk of a more severe COVID-19 infection (Holman et. al, 2020). The pathway also proposes proactive interventions to help reduce these risks, in order to keep people with diabetes as safe and as healthy as possible.

In summary, this pathway seeks to deliver the following benefits

1. Prevent or delay the progression of DKD in patients that are identified.

2. Support individuals with DKD to make informed decisions with their clinicians and ensure that they receive clear information about their diagnosis and what they can do to help prevent or delay progression of DKD.

3. Positive clinical outcome(s) due to risk stratification, implementation of interventions and use of clinical judgement.

4. Reduce risk of severity of COVID-19 infection through improving modifiable risk factors (based on current evidence).

5. Standardise clinical care for people with DKD across London by providing clear recommendations in the pathway (evidence based and/or expert opinion) that can be locally adapted if necessary.

6. Optimise use of available resources through risk stratification which determines who may be appropriate to review and provide care to the patient.

Can I make adaptions to the pathway?

A core aim of the pathway is to ensure optimal care by reducing unwarranted variation in care that may exist. Nevertheless, we recognise that each STP/ICS/GP practice will have differing resources and capacity to deliver. Hence, the pathway could be adapted locally to account for this. However, we recommend that the core principles, stages and interventions remain unchanged.

Who developed the pathway?

On behalf of the London Diabetes Clinical Network, the pathway has been developed in collaboration with GPs representing all 5 STPs/ICSs across London, with ongoing input from diabetologists and nephrologists. The pathway has been tested in the EMIS GP software system in North Central, North East and South East London (SEL). It will also be tested in SystmOne in London, to ensure that it is fit for purpose.

The pathway was approved by the London Diabetes Transformation Board on the 18th November and is shown below as an attachment with supportive guidance and hyperlinks.

Step-by-step guide for GP practices using EMIS

Individual GP practices should decide who can perform the following process below, or parts of it, from the practice team. For instance, a practice manager, administrator, nurse, pharmacist, IT manager or a GP. This process should take no more than 20 minutes to complete.

1. Open this folder and import the EMIS Search into your GP clinical system

2. Run the search.

3. A list of patients with diabetes whose most recent eGFR<45ml/minute will be generated. This list can be transferred into the pre-made excel spreadsheet (see example below) if this is easier for people to do. Columns A-G will need to be in-putted manually. Columns H-J will be automatically generated based on your input.

4. Once you have populated the spreadsheet, you will need to select the DKD risk category in the last column (K).

5. Repeat the above process as required to identify new patients, but not to re-stratify patients.

Stakeholder’s involved

The pathway has been developed through close collaboration with a range of senior stakeholders across London including:

· Dr. Neil Ashman: Nephrology Consultant – Barts Health NHS Trust, Deputy Chief Executive – The Royal London, Mile End and Community Health Services Site Management Team

· Dr. Andrew Frankel: Nephrology Consultant – Imperial College Healthcare NHS Trust

· Dr. Tony Willis: GP – Richford Gate Medical Practice, Clinical Director for Diabetes – North West London Health and Care Partnership

· Dr. Gavin Steele: GP

· Anna Hodgkinson: Consultant Pharmacist – Lambeth Diabetes Team, Guy's and St Thomas' NHS Foundation Trust, South East London CCG

· Catherine Croucher: Consultant in Public Health – NHS London and NHS England

· Dr. Alice Rickford: GP – Pavilion Medical Centre, Member – Lambeth Diabetes Team

· Dr. Janaka Karalliedde: Diabetes, Endocrinology and Internal Medicine Consultant – Guy's and St Thomas' NHS Foundation Trust, Senior Clinical Lecturer – King's College London

· Dr. Gareth Hull: GP – Sunray Surgery, Diabetes Lead – Kingston CCG

· Carrie Gardner: Regional Programme of Care Manager Internal Medicine – NHS London and NHS England

· Stephen Cass: Director – South London Renal Clinical Alliance, Transformation Director – North London Kidney Clinical Advisory Group

· Dr. Paula Fernandes: GP – The Hammersmith Surgery

· Matahir Jahn: Clinical Systems Developer – North West London CCG

References

Holman N, Knighton P, Kar P et. al (2020) Risk factors for COVID-19 related mortality in people with type 1 and type 2 diabetes in England: a population-based cohort study. Lancet Diabetes Endocrinology 8 (10): 828-833.

NICE (2014) Chronic kidney disease in adults: assessment and management (CG182). NICE, London. Available at: https://www.nice.org.uk/guidance/cg182 (accessed 25.10.20)

Nitsch D, Caplin B, Hull S, Wheeler DC; National CKD Audit and Quality Improvement Programme in Primary Care (2017) First National CKD Audit Report. Available at: https://bit.ly/33hPZVG (accessed 25.10.20)

Marion Kerr, Benjamin Bray, James Medcalf, Donal J. O'Donoghue, Beverley Matthews, Estimating the financial cost of chronic kidney disease to the NHS in England, Nephrology Dialysis Transplantation, Volume 27, Issue suppl_3, 1 October 2012, Pages iii73–iii80, https://doi.org/10.1093/ndt/gfs269

Renal Association (2017) UK eCKD Guide: Proteinuria. The Renal Association, Bristol. Available at: https://bit.ly/3btpdxl (accessed 25.10.20)

Winocour PH (2017) Diabetes and chronic kidney disease: an increasingly common multi-morbid disease in need of a paradigm shift in care. Diabet Med 35: 300–5

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DM DKD stratification.zip

DM DKD stratification.xml

b0c70855-7bac-4b1d-baa2-934d185c6838 2020-12-31T12:46:28.2239527+00:00 a359e829-4d72-4d59-a554-ea64d177c5a5 DM renal strat GFR 2020-10-27T23:18:30.8609873+00:00 0492f1ae-58fd-4fda-a7b4-68d677f83ee5 PATIENT ee9a91c9-49b7-4f93-83f0-919fd4e9e378 BASELINE AND 94c727cd-09f1-4b14-b156-fb20d763970b EVENTS Clinical Codes false 7b6a929d-cbff-4a56-99ba-277271e51230 READCODE Clinical Code IN 575c54e8-daca-4ed1-b23d-847a5be4ca0c SNOMED_CONCEPT 197761014 Type 2 diabetes mellitus true 197984010 Type 1 diabetes mellitus true NEXT REJECT a0b93a9f-7e17-460f-9182-f1561557788b AND 24612b70-9146-4e25-9381-2446baaa09f1 EVENTS Clinical Codes false 94a4ffe5-fea9-4fc5-87c0-4a95c3604b68 READCODE Clinical Code IN 0c81ebf4-2905-4c06-8756-f1635ac95aae SNOMED_CONCEPT 976481000006110 GFR (glomerular filtration rate) calculated by abbreviated Modification of Diet in Renal Disease Study Group calculation true 1 DATE Date DESC a29fc1af-f6e1-471e-9114-982531c046ee NUMERIC_VALUE Value IN 45 LTEQ SELECT REJECT ce6c553f-cd81-46f6-be2d-e7d2521f232b

V4-Excel DKD Risk

Stratifier for DM pts GFR less than45.xlsx

Sheet1Date of risk stratfication search:Patient ID number:Surname:First name(s): DOB:Most recent eGFR (ml/min):Next most recent eGFR (ml/min):Difference between two eGFR readings:Drop of >10ml/min between the two results? (Y/N) (if Y, Rapid DKD prgression)Is eGFR less than 30ml/min? (Y/N) (if Y, Rapid DKD prgression)DKD risk category: 0NY0N0N0N0N0N0N0N0N0N0N0N0N0N0N0N0N0N0N0N0N0N0N0N0N0N0N0N0N0N0N0N0N0N0N0N0N0N0N0N0N0N0N0N0N0N0N0N0N0N0N0N0N0N0N0N0N0N0N0N0N0N0NY0NN0N0NRapid DKD0NAt risk0N0N0N

DKD Risk

Stratification Pathway-v20.pdf

STARTIdentify all patients in GP practice with a registered

diagnosis of diabetes

Identify the individuals whose most recent eGFR reading is <45ml/min

For these patients with diabetes

Identify the individuals whose previous eGFR is <45ml/min

For these patients

Is there a drop of >10ml/min between the 2 results OR is the most recent eGFR <30ml/min?

Compare the 2 eGFR results

OneLondon Diabetic Kidney DiseaseRisk Stratification Pathway

for Winter 2020/2021 & COVID-19

RAPID DKD PROGRESSION

SEEK ADVICE: - Urgent virtual review within 2 weeks - Review case with peers/practice colleagues and/or- Contact specialist virtual local renal services for management advice- Decide on an individual basis whether patient can be managed in primary care or needs referral to specialist renal services

YES If patient NOT under specialist renal services already

AT RISK Prioritise for clinical intervention due to high risk of DKD progression

NO

GP/DIABETES NURSE TO MANUALLY REVIEW PATIENT NOTES: - If patient has type 1 diabetes, make an urgent referral to local type 1 specialist care team for all further input - Check if patient under specialist renal services - Review most recent BP, ACR and bloods (eGFR, HbA1c, FBC and total cholesterol) - Conduct medication review (ideally by practice pharmacist) - N.B. Patients with an elevated HbA1c and a BMI >25kg/m2 (overweight) may be at greater risk of getting more severe COVID-19 infections, and should thus be prioritised

AHP/HCA (or equivalent; to be decided by individual practices) phones patient and completes attached template during consultation: - Asks the patient if they have been unwell recently - Advises patient when to get in touch with the GP practice if they become unwell- Basic check to see if the patient has any problems with their medications

FACE TO FACE CONSULTATION (GP/DIABETES NURSE) 1. Discuss with patient: - What their eGFR and ACR is - What DKD is and its long term implications - Importance of HbA1c and BP targets - Importance of medication adherence - Avoid using any NSAID's - Increased risk of AKI during acute illness - Current urine output and any recent urinary symptoms 2. Titrate/add medications: - Optimise ACE or ARB to maximimum dose unless contraindicated and monitor renal function- Aim for target BP of 120-130/70-80 mmHg - Optimise diabetic medications to reach an individualised HbA1c target, ideally <59mmol/mol - Treat hyperlipidaemia to target

Direct patient to Sick Day rules resource: https://trend-uk.org/wp-content/uploads/2020/03/A5_T2Illness_TREND_FINAL.pdf

If patient has been unwell recently or if patient reports any problems with medications, refer back to GP or Diabetes Nurse for further input

Send ALL patients the following resource links by text message, email or post: 1. Advice on eating a low salt diet and alcohol moderation for blood pressure http://www.bloodpressureuk.org/media/bpuk/docs/HealthyEatingBloodPressure_web.pdf 2. Infomation that explans DKD and gives general healthy lifestyle advice https://www.diabetes.org.uk/resources-s3/2018-02/Diabetes%20UK%20Information%20Prescription_Kidney%20health.pdf 3. Sick Day Rules https://trend-uk.org/wp-content/uploads/2020/03/A5_T2Illness_TREND_FINAL.pdf

Refer to your local guidelines to titrate medications for hyperlipidaemia, hypertension and diabetes medications. You can also refer to NICE NG28 national guideance to adjust diabetes medications: https://www.nice.org.uk/guidance/ng28/resources/algorithm-for-blood-glucose-lowering-therapy-in-adults-with-type-2-diabetes-pdf-218560417 Clinician to use the following to guide action regarding Acute Kidney Injury: https://www.thinkkidneys.nhs.uk/aki/wp-content/uploads/sites/2/2017/06/Quick-reference-guide-FINAL.pdf https://www.thinkkidneys.nhs.uk/aki/wp-content/uploads/sites/2/2016/03/Recognising-and-Responding-to-Acute-Kidney-Injury-in-Primary-Care-Table-2.pdf

REPEAT BP/ACR/BLOODS: If bloods + BP are > 12 months old - obtain repeat BP, ACR, eGFR, HbA1c and total cholesterol If bloods + BP are 6-12 months old - consider obtaining repeat BP, ACR, eGFR and HbA1c. Clinical judgement must be used. If bloods +BP < 6 months old - existing results can be used

If required, signpost to locally available lifestyle interventions (via text/email): 1. Smoking cessation (if applicable) 2. Weight loss (if BMI >30kg/m2) via local weight loss services and/or exercise on prescription

If concerns with current management and/or modifiable risk factors

1

2

3

4

5

6

7

8

If no concerns with current managment

Is there is now a drop of >10ml/min between the last 2 eGFR results or is the eGFR <30ml/min/ACR >30mg/mmol?

9

NO

YES

https://trend-uk.org/wp-content/uploads/2020/03/A5_T2Illness_TREND_FINAL.pdf

http://www.bloodpressureuk.org/media/bpuk/docs/HealthyEatingBloodPressure_web.pdf

https://www.diabetes.org.uk/resources-s3/2018-02/Diabetes%20UK%20Information%20Prescription_Kidney%20health.pdf

https://www.diabetes.org.uk/resources-s3/2018-02/Diabetes%20UK%20Information%20Prescription_Kidney%20health.pdf

https://www.diabetes.org.uk/resources-s3/2018-02/Diabetes%20UK%20Information%20Prescription_Kidney%20health.pdf

https://www.diabetes.org.uk/resources-s3/2018-02/Diabetes%20UK%20Information%20Prescription_Kidney%20health.pdf

https://www.diabetes.org.uk/resources-s3/2018-02/Diabetes%20UK%20Information%20Prescription_Kidney%20health.pdf

https://www.diabetes.org.uk/resources-s3/2018-02/Diabetes%20UK%20Information%20Prescription_Kidney%20health.pdf

https://trend-uk.org/wp-content/uploads/2020/03/A5_T2Illness_TREND_FINAL.pdf

https://trend-uk.org/wp-content/uploads/2020/03/A5_T2Illness_TREND_FINAL.pdf

T2DM: https://www.nice.org.uk/guidance/ng28/resources/algorithm-for-blood-glucose-lowering-therapy-in-adults-with-type-2-diabetes-pdf-2185604173

https://www.thinkkidneys.nhs.uk/aki/wp-content/uploads/sites/2/2017/06/Quick-reference-guide-FINAL.pdf

https://www.thinkkidneys.nhs.uk/aki/wp-content/uploads/sites/2/2016/03/Recognising-and-Responding-to-Acute-Kidney-Injury-in-Primary-Care-Table-2.pdf

https://www.thinkkidneys.nhs.uk/aki/wp-content/uploads/sites/2/2016/03/Recognising-and-Responding-to-Acute-Kidney-Injury-in-Primary-Care-Table-2.pdf

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