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 morbiditiesPrepare for RRT ACE inhibitorsMalnutritionCardiac diseaseEducation BP controlAnaemiaVascular diseaseInformed choice of RRT/conservative management Glucose controlCalcium Phosphate PTH Drug interactionsTimely access placement/ Transplant Listing Smoking cessationAcidosisNeuropathy/ Retinopathy Timely initiation of RRT Management of CKD CKD = chronic kidney disease; RRT = renal replacement therapy Early Detection of CKD Think/Report eGFR

NEOERICA: percentage recording of creatinine and prevalence of Stage 3–5 CKD by age –2425–3435–4445–5455–6465–7475–8485+ Age groups Patients (%) Recorded serum creatinineStage 3–5 CKD

Source of Late Referrals Lamiere - NDT 1999

DIABETOLOGISTS CARDIOLOGISTS GEN. MEDICINE GEN. PRACTICE NEPHROLOGISTS SILO MANAGEMENT

DIABETOLOGISTS CARDIOLOGISTS GEN. MEDICINE GEN. PRACTICE SILO MANAGEMENT CHRONIC DISEASE MANAGEMENT INTEGRATED MANAGEMENT

GFR CKD: An Overall Health Approach Complications CKD risk factor reduction, screening for CKD Diagnosis and treatment, treat comorbid conditions, slow progression Estimate progression, treat complications, prepare for replacement Replacement by dialysis and transplant Screening for CKD risk factors Kidney failure Damage Increased risk NormalDEATH

CKD Stage 1, 2,3 Education Blood pressure Smoking cessation Lipid control Medicines Management Diet advice Exercise Psychosocial support CKD Stage 4 Anaemia Acidosis Bone disease Preparation/choice CKD Stage 5 RRT PD HP Tp Glycaemic control Complications eyes feet kidney Radiology Surgical interventions Anti coagulation Anti arrhythmics Medical treatment of CHF + DM+ CHD Cardiac Kidney Diabetes

QOF indicators for CKD 2009 Register of patients over 18 with CKD Percentage of patients on the CKD register whose notes have a record of BP reading in last 15 months % Percentage of patients on the CKD register in whom the last BP reading, measured in the last 15 months was 140/85 or less % Percentage of patients on the register with hypertension and proteinuria treated with an ACE-I or ARB (unless side-effects are recorded) % Percentage of patients on the register whose notes have a record of urine ACR or PCR in the previous 15 months %