CKD Prevention & CRM
Purpose
We work with our partners to transform CKD diagnosis and care across London and Surrey Heartlands. We strive to improve outcomes for people living with kidney disease through early identification, accurate coding, and care optimisation to prevent progression, thereby protecting the kidneys and saving lives. We aim to establish an approach to CKD care in the context of cardiorenal metabolic (CRM) disease by working with partner Networks and driving a more integrated approach to the care of people with CRM disorders.
LKN Leads
Andrew Frankel
Co-Clinical Lead
Linda Tarm
Co-Clinical Lead
Prevention in London
There are approximately 86,000 adults living in London with undiagnosed Chronic Kidney Disease (CKD). Many of these individuals suffer with CKD in the context of cardiac and metabolic disease.
The relationship between CKD and cardiac disease increases as kidney function declines. This increased risk of cardiovascular events, and also of end-stage kidney failure, could be greatly reduced through early CKD identification, appropriate/consistent coding of CKD and effective evidence-based management strategies.
NICE (National Institute for Health and Care Excellence) recommends that people at risk of CKD should be screened regularly with a kidney health check including an urinary Albumin Creatinine Ratio (uACR) test and a blood test to assess glomerular filtration rate (eGFR). Testing uACR identifies CKD much earlier than relying on changes in eGFR only.
We are committed to supporting primary care to improve formal CKD screening, diagnosis and coding. We will use national CVD-Prevent audit data to improve understanding of our performance in these areas.
We are in a new era of CKD treatment with many new agents established and in development. These could transform the outlook of people with CKD by significantly reducing their risk of both cardiovascular harm and reaching end-stage kidney failure.
We have an opportunity to identify, code and manage CKD early, preventing or delaying progression, and protecting the kidneys. By supporting primary care with early identification tools and resources, teams, and incentives to deliver effective interventions, there is an opportunity to deliver improved outcomes, protecting the kidneys and heart, and providing better patient experience.
Now is the time to act.
Aims and objectives of the workstream:
Aims:
- Data is used to help ICSs understand and drive up performance in CKD care
- Strategic commissioning decisions in London ICSs influenced to ensure continued investment in CKD prevention
- Early identification in underserved populations across London improved through CKD community outreach programmes
- Each London sector has an effective programme to support people living with CKD stages 1-3 to understand and manage their condition
- CKD plans are aligned with a CRM approach to improve integrated CKD care
- Enthusiastic and committed people from each ICS work together to achieve improvements in CKD and CRM care in London
Objectives:
- Highlight and promote use of the LKN quarterly report that compares each ICS’s CKD data.
- Contribute towards developing an economic evaluation of the value of early detection and optimisation
- Develop practical guidance in the form of a toolkit on setting up a CKD community outreach programmes, based on the Hidden CKD model
- Communicate and share the toolkit with London ICSs to encourage consideration of similar programmes
- Develop and host live and interactive educational webinars as exemplars for what could be delivered for people with CKD stages 1-3 living in London and Surrey Heartlands
- Co-create and share a ‘Medicines & Kidney’ resource
- Work collaboratively with the 3Ps renal evaluation team to help ensure successful delivery of the evaluation of the 3Ps CKD projects
- Work with the London diabetes and cardiac Networks to co-develop and deliver appropriate resources that support ICSs in their endeavours to develop CRM models of care
- Collaborate with third sector organisations when opportunities arise
- Establish a pool of people to facilitate regular communications and as a way to support the workstreams aims and objectives
Completed Work
Pathways
LKN CKD Early Identification & Optimisation Pathways
1. Identify CKD early by checking kidney health in adults living with diabetes and/or hypertension.
2. Save lives by following our ‘3 key interventions within 3 months’ in adults living with CKD, with or without diabetes.
Guidance documents
Guidelines on CKD Coding in Primary Care
London Kidney Network Expert Consensus
Interpreting uACR & eGFR results
For clinicians
Metrics
Performance Metrics
Current agreed CKD performance metrics reported in the LKN quarterly report.
Other CKD Prevention & CRM Resources
Primary Care Resources Package
Helpful Patient Information Package
Sick Day Medication Guidance in CKD
Resources
Primary care patient searches and dashboard
Downloable searches that identify and create reports of your patients at risk of CKD or with CKD in SystmOne and EMIS
Information for people at risk of CKD or living with CKD
Educational leaflets and videos to help patients to understand their CKD diagnosis and how they can manage their condition
Primary care CKD review templates
Downloadable CKD templates available in SystmOne and EMIS that can be used to review patients with CKD
CKD Early Identification & Intervention Toolkit
Visit the ISN website and view the toolkit.
Starting and Sustaining Early CKD Detection and Intervention Programs
Visit the ISN website and view the toolbox.
North West London Case Study
The North West London (NWL) consortium led a project with the London Kidney Network to identify and tackle the CKD related challenges facing primary care and patients. Click here to learn more about how the project was delivered and access the resources for patients and primary care.
