Population-wide Chronic Kidney Disease Management Reducing the Incidence of Kidney Failure

Transcription

1 Population-wide Chronic Kidney Disease Management Reducing the Incidence of Kidney Failure Dr Hugh Rayner MD FRCP DipMedEd Consultant Nephrologist Heart of England NHS Foundation Trust

2 Pathology and renal services to c.900,000 Birmingham

3 Improving CKD outcomes Before: Age CKD Dialysis Age

4 Improving CKD outcomes Before: Age CKD Dialysis Age After: Age CKD Transplant Age

5 CKD management program (2003-6) Start RRT Slow progression Identify patients at high risk Primary care Self care

6 How well are your kidneys working now?

7 Reviewing U&E results Date Creatinine egfr

8 egfr ml/min/1.73m year old man, type I diabetes with nephropathy

9 Support self-care Dear Mr Bloggs, It was good to see you in clinic. I was sorry to tell you that your kidney function is still going down... Yours sincerely egfr ml/min/1.73m Write letters directly to patients Share the egfr graph

10 Most people with diabetes do not develop kidney failure Prevalence of dialysis or transplantation in type 2 diabetes: = 0.26% = 0.56% England National Diabetes Audit

11 I ve got diabetes, high blood pressure, protein in my urine and my kidney function is slowly getting worse Where s Wally?

12 Risk filters Secondary care Falling egfr Start RRT Slow progression Identify patients at high risk Primary care Reduced egfr or Heavy proteinuria Self care

13 Nephrology CKD register Patient Administration System Pathology laboratory Patient attends nephrology or diabetes clinic Proton CKD Register Blood test results Weekly extracts listing patients with: egfr <15, for multidisciplinary pre-esrd team review diabetes + age<65 + egfr<50 for egfr graph review diabetes + age>65 + egfr<40

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15 Sudden deterioration in egfr egfr

16 Gradual deterioration in egfr egfr

17 400 Attendances at the diabetes-kidney clinic Follow-up visits 150 First visits

18 Preserving kidney function in diabetic nephropathy BP controlled

19 Patients starting RRT at Heart of England Foundation Trust Pre-ESRD team Primary care education egfr reporting GP HT and diabetes QOF payments Diabetes egfr surveillance Letters to patients GP CKD QOF payments Incident RRT rate per million population aged over 14 years Number starting RRT

20 Lowest rate of late presentation for chronic dialysis 5.7% Percentage of patients presenting <90 days prior to starting RRT, 2012/2013 HEFT % E, W & NI %

21 England B Heart Ports Stevng Carlis Sund Dudley Norwich Bradfd Donc Leeds Dorset Nottm Prestn Sheff Glouc Derby York Sthend Oxford Exeter Covnt Kent Newc Bristol Truro Leic Colchr Shrew L Kings Carsh L West Middlbr Basldn Liv Roy M RI Redng Wolve Hull Liv Ain Camb Brightn Chelms L Rfree Stoke B QEH Wirral Ipswi N Ireland West NI Antrim Ulster Newry Belfast Wales Wrexm Cardff Bangor Clwyd Swanse England N Ireland Wales E, W & NI Highest rate of early presentation for chronic dialysis % Percentage of patients presenting > one year prior to starting RRT, 2012/2013 UK Renal Registry Report 2014

22 Best vascular access performance in the West Midlands % of haemodialysis patients using an AV-fistula 100% 2014/15 95% April 90% May 85% June 80% 75% 70% 65% 60% 55% 50% HEFT UHNM SaTH RWH Dudley UHCW UHB July August September October November December January

23 Survival of incident patients UK Renal Registry Report 2013

24 Heart of England Kidney Function Monitor Patient ZZC Date of Birth 17-Aug-1938 Sex M Requesting Dr K Arora Location Perry Park 291 Walsall Rd Clinician Date/Time of Test 11-Apr :13 Estimated GFR 35 (ml/min) Since 2012: Laboratory surveillance and selective graphical reports /01/ /01/ /01/ /01/ /01/2012 Est GFR (ml/min) GFR if Afro Caribbean Marked as Inform Clinician Marked as Urgent CKD Made Easy a guide for general practice Other Tests From The Last 5 Years Test Highest Date Latest Date HbA1c 7.6 % 27/02/ % 27/02/2012 Serum K 5.1 mmol/l 11/04/ mmol/l 11/04/2012 Serum Na 144 mmol/l 15/09/ mmol/l 11/04/2012 Serum Urea 12.4 mmol/l 11/04/ mmol/l 11/04/2012 Urine Protein 0.27 g/l 15/09/ g/l 27/02/2012 Urine albumin:creatinine ratio 30.5 mg/mmol 15/09/ mg/mmol 27/02/2012 Diabetic Status on Renal Database Not Diabetic Dear Dr Arora, This results for this patient have reviewed as part of our departments system for monitoring chronic kidney disease using cumulative graphs of egfr. Based on our criteria, agreed with the renal medicine department, this patient has been identified as at increased risk of progression to end-stage kidney disease. If you requirefurther advice or information for the management of this patient please contact Dr Hugh Rayner at Birmingham Heartlands Hospital. Google: CKD Made Easy Kennedy DM, Chatha K, Rayner HC Laboratory database population surveillance to improve detection of progressive chronic kidney disease. Journal of Renal Care 2013; 39 Suppl 2:23-9 hugh.rayner@heartofengland.nhs.uk for a copy of 'CKD Made Easy'. Please quote this patient's NHS number.

25 GP feedback (n=36) 30% usually looked at only the last few results 74% found the graphical egfr report useful 41% had changed patient management in response to the report Average ease of use of the graphs = 8 out of 10 (10 = easiest)

26 GP feedback I would be grateful for your advice regarding the above 91 year old lady. My query is in regards to her deteriorating egfr which has been made clear by a graph that had been sent to me.

27 UK prevalent population

28 Prevalent population on RRT 800 UK UK 700 Heart of England Trust

29 HEFT prevalent population with ESRD Total dialysis (HD + PD) Transplant

30 Summary of the benefits Clinical Fewer patients reaching end-stage kidney failure Financial Cost of dialysis program stabilised Environmental Fewer patients attending hospital clinics Social Access to nephrology based upon health need regardless of age, ethnicity and GP expertise in CKD Informed and shared decisions through better understanding of CKD by use of egfr graphs Consultants in control of their workload

31 Thank you to my wonderful Steve Smith Mark Temple Mark Thomas Indy Dasgupta Jyoti Baharani Vijay Suresh colleagues Does Community-Wide Chronic Kidney Disease Management Improve Patient Outcomes? Nephrology Dialysis Transplantation March 2014

32 50YearsofDialysis.com