Chronic Kidney Disease

As part of the wider Cardiovascular Disease Prevention Programme, HI NENC is delivering a Chronic Kidney Disease (CKD) programme. The CKD programme will focus on improving earlier diagnosis and supporting early medical treatment of people with CKD to slow disease progression and reduce the development of cardiovascular comorbidity.

The programme will be delivered in collaboration with the NENC Renal Operational Delivery Network.

Aim

To help prevent cardiovascular disease such as heart failure and to reduce the progression to end stage renal disease, including the requirement for dialysis.

Delivery in the North East and North Cumbria

HI NENC will support Primary Care Networks (PCNs) to implement the North East and North Cumbria renal Operational Delivery Network Guidance for CKD and improve diagnosis rates in people with CKD.

A key priority of the programme is to reduce health inequalities; we know that approximately 50% of coded CKD resides in 20% of practices within the areas of highest socio-economic deprivation. We aim to work with our partners, including the North East and North Cumbria Integrated Care System (ICS) to ensure that activities are focused on areas of higher deprivation and groups of people who are at higher risk of developing cardiovascular disease as a result of their CKD.

Programme activities will include:

Detection of people with CKD through case finding interventions through identifying patients on electronic record systems who may have CKD but who are not coded as such based on previous lab results.
Where people with CKD have been identified, risk stratification will ensure optimised management according to National Guidelines.

Benefits

Improving CKD outcomes in this way will deliver savings for the region through improved coding, CKD identification and early treatment resulting in halting or delaying End Stage Kidney Disease and reduced dialysis.
The development of best practice for clinicians and healthcare providers. This will include resources to support and disseminate best practice across the region, embedding and training a primary care pharmacist to promote a culture of early identification, and treatment of CKD meeting GIRFT goals.

CDRC

Using the searches provided by Clinical Digital Resource Collaborative (CDRC), it is possible to identify cohorts referenced above to support GP practices in managing their CKD populations.
CDRC digital resources are designed and developed in the North East and North Cumbria by local clinicians. Their work is supported by NHS England, North of England Care System Support (NECS) and HI NENC.
All CDRC resources are available at no cost to Primary Care users and available in SystmOne and EMIS. Click the links below for more information.

SystmOne resources

EMIS resources

Hear from Dr Tom Zamoyski in the below video, who demonstrates how the CKD SystmOne resources can be used.

CKD webinar series for primary care clinicians

Watch back a series of three educational webinars about chronic kidney disease (CKD) and its significance as a cardiovascular risk factor. HI NENC hosted the series to help care teams identify CKD earlier and provide resources to improve outcomes for patients.

These webinars are ideal for staff in primary care networks (PCNs), including nurse practitioners, pharmacists, and GPs.

Watch the webinars via the link below. Please note this is a playlist and all the videos can be watched via the below link.

Facts.CKD Gateshead Project

A project is underway to work with a small number of GP practices in deprived areas in Gateshead to detect CKD early, to ultimately prevent progression to end stage kidney disease. With a focus on health inequalities and environmental sustainability, the project is part funded by the NENC Renal Network and Astra Zeneca with HI NENC providing project management.

Funding will support the employment of a health care assistant and pharmacist who will pilot new approaches to identify previously undiagnosed CKD patients and existing CKD patients who are eligible for optimised treatments. Key aims of the project are to –

Improve accuracy of CKD registers, identifying patients with CKD on a negative disease trajectory early.
Increase the percentage of patients receiving NICE appraised medical optimisation, prioritising patients with highest health inequalities first.
Assess healthcare utilisation to inform onwards funding and system sustainability.
Leave a legacy through training local teams on multimorbid CKD reviews and integrate CDRC software across Gateshead to support ongoing caseload management.

In addition, there will be dedicated access to 60 hours of Renal Clinics provided by NENC Renal Operational Delivery Network.

For more information contact Karen Verrill.

Resources

For healthcare professionals

Identification and Management of CKD in Primary Care: Medscape UK Guidelines

Healthcare professionals in the North East and North Cumbria have developed guidelines for primary care. These ‘Primary Care Hacks’ aim to provide a quick reference guide to support earlier identification and treatment of CKD in the community.

Download the Identification of CKD in Primary Care Guide

Download the CKD Interventions in Primary Care Guide

Educational webinar series

HI NENC hosted a series of three webinars about chronic kidney disease (CKD) and the resources available to help you to improve outcomes for people in the region living with the condition. The sessions were led by expert clinicians in NENC, who have shared best practice and case studies.

The webinar series has been developed to support primary care to identify people with CKD earlier and share the resources available to optimise the treatment and management of patients.

View the playlist

CVD prevent audit tools

CVDPREVENT is a national primary care audit tool that automatically extracts routinely held GP data covering diagnosis and management of high risk conditions that cause stroke, heart attack and dementia, including Chronic Kidney Disease

The tool provides a foundation for quality improvement in individual GP practices and supports primary care in understanding how many patients with CKD are potentially undiagnosed, or under or over treated. The audit provides data to highlight gaps, identify inequalities, and opportunities for improvement.

Visit the website for resources

Primary Care Cardiovascular Society (PCCS) education module

Chronic Kidney Disease Quality Improvement Programme

This Quality Improvement (QI) programme is designed to support primary care teams to understand the importance of Chronic Kidney Disease (CKD), how to improve coding, embedding processes to detect CKD, and how to optimise patients with CKD. The programme can be found on the PCCS website.

For patients

Useful websites

Kidney Care UK

The kidney patient support charity, Kidney Care UK provides practical, emotional and financial support to kidney patients and their families. Their website includes a wealth of information about chronic kidney disease and its treatments including dialysis and transplant.

Patient animations

A series of animations for patients can be found below. You can also view them through the YouTube playlist here.

The content has been created to help people understand their kidneys better, how to keep them healthy and what medicines can help their kidneys. These videos are for information only and not a substitute for medical advice.

Please note: HI NENC is not responsible for the content within these videos. The animations have been created by clinicians at University Hospitals of Leicester NHS Trust, who have kindly given HI NENC permission to share amongst our networks.