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.


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.


  • 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.


  • 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 EnglandNorth of England Commissioning 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.

For more information contact Chris Gray.


CKD interventions in primary care

Healthcare professionals in the North East and North Cumbria have developed guidelines for primary care, to support earlier identification and treatment of CKD in the community.

Download the resource

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.

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.

Your kidneys and what they do

What is Chronic Kidney Disease (CKD)

What is my risk of kidney failure with CKD

What are SGLT2 inhibitors – Chronic Kidney Disease

How to keep your kidneys healthy

High blood pressure and the kidneys

Anaemia and the kidneys

Tests to check kidney function

What is dialysis

What is a kidney transplant

High cholesterol and the kidneys

Chronic kidney disease and mineral bone