Approximately 15% of the adult population have CKD
The current model of kidney care is referral pathways that are based on eGFR; this is consistent with the national guidelines
The proposed model of kidney care utilises the CKD expertise within the catchment area
The core issues are that
1. Identification
2. Monitoring
They are then seem people aged 18 years and older included on the QOF CKD registers in the West Midlands. CKD is a major risk factor for cardiovascular disease and mortality but is largely asymptomatic until it reaches an advanced stage. It is estimated that there could be approximately 83,000 people who are undiagnosed in the West Midlands. Kidney function is measured by a simple blood test (eGFR). In CKD, depending upon the underlying cause, eGFR can remain stable or decline (progressive CKD). The majority of patients retain sufficient kidney function to live out their natural life. However, those whose eGFR progressively declines benefit from early specialist treatment to reduce the rate of decline and hence the likelihood of requiring dialysis or a kidney transplant [1]. The traditional model of referral of patients with CKD from primary to secondary care is based upon the staging of CKD which is defined by the level of eGFR. Patients with CKD stage 3 are generally cared for in primary care and referred to secondary care if they reach stage 4 (defined by the patients’ eGFR falling below 30 ml/min/1.73m2) as defined by NICE guideline CG 73. Patients with declining function but still within stage 3 may not be recognised and so miss an opportunity to have earlier specialist care [2]. This can lead to late presentation for RRT, which remains an important cause of avoidable harm and premature death. Once in secondary care, many patients with stable CKD continue to attend outpatient clinics. They could be monitored in primary care if there was a system of remote surveillance of their eGFR trend to ensure it stays stable [2]. Optimal management of CKD relies upon: a) the patient having a sufficient understanding of his/her condition and its treatment; b) the primary care team monitoring the patient’s progress and modifying the treatment plan accordingly; and c) the nephrology specialist in secondary care providing advice and guidance at appropriate times and seeing patients in outpatient clinics only when that adds value to the patient. The HEFT renal and pathology departments operate an innovative system for early detection and treatment of patients who are at the highest risk of developing end stage renal disease (ESRD) [3]. In this system, the pathology laboratory uses a database containing biochemical data from patients (integrating results on blood samples taken in all settings) to generate cumulative graphs of eGFR. The software facilitates the identification of those patients with deteriorating kidney function, classifying them as low, intermediate or high risk. For intermediate or high risk cases, the requesting primary care clinician is sent a paper report of the eGFR graph with advice about how to access nephrology advice. Once stable, patients can be discharged from the outpatient kidney clinic and their kidney function followed remotely via their eGFR graph. Late presentation for RRT is a powerful and modifiable predictor of poor outcome. Consequences of late referral include anaemia and bone disease, low prevalence of permanent access, delayed referral for transplantation, reduced choice of renal replacement modality, worse psychological adjustment to ESRD, longer initial hospitalisation and increased mortality [5]. The rate of patients presenting late to HEFT before starting dialysis, i.e. within 90 days, has been the lowest in the UK since 2009.