Managing the Epidemic of CKDThe UK Model

Dr Donal O’DonoghueNational Clinical Director for Kidney Care

Actualités Néphrologiques Jean HamburgerHôpital Necker, Paris

29 April 2008

UK Modality Trends 1982 – December 2006

UK Renal Registry 10th Annual Report 2007

Timely Vascular Access

Standard 3“All children, young people and adults with established renal failure are to have timely and appropriate surgery for permanent vascular or peritoneal dialysis access, which is monitored and maintained to achieve its maximum longevity.”

Accelerated processes for Acute Uraemic Accelerated processes for Acute Uraemic EmergenciesEmergencies

• Prevention and detection of early CKD• A patient centred service that supports the

person in managing their condition to achieve the best possible quality of life

• Minimising the consequences of CKD• Prompt identification of AKI• Preparation and choice for RRT

National Service Framework for Renal Services 2004-5

National Service Framework Standards

• People given timely evaluation of prognosis and information about choices and end of life care based on agreed palliative care plan

• Those likely to benefit to be transplant listed

• Timely surgery for access• Dialysis designed around individual needs

National Service Framework for Renal Services 2004-5

National Service Framework Standards

Provision and commissioning of kidney care

EOL Care

Supportive & palliative care

Modified from Levey AS et Al . KI 2005:2089-2100

Public HealthPrimary Care

Specialist Kidney Care

Vascular Risk Assessment and Management

Vascular Risk Assessment and Management

Kidney Disease 2006St

age

of K

idne

y D

isea

se

90 460

60

6

380

60

15

30

(GFR

)(G

FR)

11

22

33

44

55

Stag

e of

Kid

ney

Dis

ease

90 460

60

6

380

60

15

30

(GFR

)(G

FR)

11

22

33

44

55

90 460

60

6

380

60

15

30

(GFR

)(G

FR)

11

22

33

44

55SM

R

Age (years)John et al. AJKD 2004;43(5):825–35

0

5

10

15

20

25

30

35

40

< 60 60 - 69 70 - 79 > 80

SMR

Age (years)John et al. AJKD 2004;43(5):825–35

0

5

10

15

20

25

30

35

40

< 60 60 - 69 70 - 79 > 80

0

10

20

30

40

50

60

70

80

90

100

110

120

130

-2000 -1750 -1500 -1250 -1000 -750 -500 -250 0 250 500 750 1000 1250 1500 1750 2000

Referral time (days)

GFR

(mls

/min

)

=Pre referral slope=Post referral slope

Jones C et al Renal Association 2004

0

10

20

30

40

50

60

70

80

90

100

110

120

130

-2000 -1750 -1500 -1250 -1000 -750 -500 -250 0 250 500 750 1000 1250 1500 1750 2000

Referral time (days)

GFR

(mls

/min

)

=Pre referral slope=Post referral slope

Jones C et al Renal Association 2004

Common Harmful TreatableO’Donoghue DJ 2004

+ / -

+ / -

+ / -

+ / -

+ / -

+ / -

Proteinuria

<15 (or dialysis)Kidney failure5

15-29Severe ↓GFR4

GFR < 60 ml/min for ≥3 months ±kidney damage

45-59

30-44

Moderate ↓GFR

Moderate ↓GFR

3A

3B

60-89Kidney damage, mild ↓GFR2

Kidney damage for ≥3 months

≥90Kidney damage, N or ↑GFR1

QualifierGFRDescriptionStage

Edinburgh Consensus Conference February 2007

Classification of CKD 2007

SCr 120, eGFR 30 ml/min SCr 120, eGFR 130 ml/min

eGFR = % Kidney Function

0

20

40

60

80

100

ReciprocalSCr

Cockroft-Gault

24-HourCreatinineClearance

ReciprocalSCr [C]

Cockroft-Gault [C]

24-HourCreatinineClearance

[C]

MDRD 6Parameter

MDRD 4Parameter

Accu

racy

, %Percent of estimates within 30% of the measured GFR in theMDRD Study validation sample (n = 558)

Redrawn from: K/DOQI Clinical practice guidelines for chronic kidney disease, Am J Kidney Dis 2002;39:S1-S266

Evolution of GFR Estimation

Report field creatinine and eGFR4 – variable ID-MS traceable version of MDRD equationUK NEQAS – derived slope adjusters for correctionWhen eGFR exceeds 89 report as >90All adult samples requesting creatinine

UK NEQAS

Implementation and Harmonisation of eGFR

April 2006

40-80%4CKD 4: Percentage of patients who are treated with an ACEi and ARB (unless a contraindication)

40-70%11CKD 3Percentage of patients with a BP of 140/85 or less

40-90%6CKD 2Percentage of patients with a record of blood pressure in the previous 15 months

6CKD 1A register of patients aged 18 years and over with CKD (Stage 3-5 CKD)

PaymentStages

Points

The CKD Domain of QOF

April 2006

11 May 2006

GPs to Shoulder the Burden of CKD

Who Looks After The Patients (%)

10.170.019.8CKD 5

14.028.857.2CKD 4

13.91.684.6CKD 3

Secondary careNephrologyPrimary Care

Impact of eGFR Reporting on Referrals – Lincolnshire PCT

Mar Apr

May Jun

Jul

Aug

Sep

Oct

Nov

Dec Jan

Feb

Mar Apr

May Jun

Jul

Aug

Sep

Oct

Nov

Dec Jan

Feb

Mar Apr

May Jun

Jul

Aug

Patie

nt n

umbe

rs

10

20

30

40

50

60

70

80

90

eGFR reporting

2004 20062005

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

CKD QOF Prev CKD Prev 18+

CKD QOF Prev 3.0% 2.6% 2.6% 2.6% 2.5% 2.4% 2.4% 2.4% 2.4% 2.3% 1.7%

CKD Prev 18+ 3.8% 3.3% 3.2% 3.2% 3.2% 3.1% 3.0% 3.0% 3.0% 2.8% 2.1%

EAST MIDLANDS

SOUTH WEST

NORTH EAST

YORKSHIRE & HUMBER

SOUTH EAST

COAST

WEST MIDLANDS

SOUTH CENTRAL ENGLAND NORTH

WESTEAST OF ENGLAND LONDON

Org Level NATIONAL National Practice Code (All) Old SHA (All) PCT Short (All)

SHA Short

Data

Chronic Kidney Disease – QOF Prevalence & Age Specific Prevalence Aged 18+ - 2006/7 – By SHA

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

4.5%

Dor

set &

Som

erse

t

Tren

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Han

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Sout

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ire

Surr

ey &

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sex

NEY

NL

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ancs

Co

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ham

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ees

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r

Leic

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utla

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ambs

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erse

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re &

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ffs

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lack

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uth

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est P

enin

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rdsh

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Gre

ater

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es V

alle

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ondo

n

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on

SW

Lon

don

NW

Lon

don

NC

Lon

don

CKD QOF Prev CKD Prev 18+

Org Level Old SHA National Practice Code (All) SHA Name (All) SHA Short (All) PCT Short (All) SHA Code (All)

Old SHA

Data

Chronic Kidney Disease – QOF Prevalence & Age Specific Prevalence Aged 18+ - 2006/7 – By Old SHA

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

CKD QOF Prev CKD Prev 18+

CKD QOF Prev 2.8% 2.4% 2.4% 2.3% 2.2% 2.2% 2.2% 1.8% 1.6% 1.6%

CKD Prev 18+ 3.7% 3.0% 3.1% 2.9% 2.8% 2.8% 2.9% 2.3% 2.1% 2.0%

OLDHAM BURY SALFORD TRAFFORDASHTON LEIGH & WIGAN

HEYWOOD/MIDDLETON/R

OCHDALE

TAMESIDE & GLOSSOP STOCKPORT MANCHESTE

R BOLTON

Org Level SHA National Practice Code (All) Old SHA Greater Manchester SHA Short (All)

PCT Short

Data

Chronic Kidney Disease – QOF Prevalence & Age Specific Prevalence Aged 18+ - 2006/7 – By PCT

Greater Manchester

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

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WIRRAL LIVERPOOL NORTH LANCS BLACKBURN/ DARWEN

OLDHAM BOLTON

Cheshire & Mersey Cumbria & Lancs Greater Manchester

CKD QOF Prev CKD Prev 18+

Org Level PCT SHA Short (All)

Old SHA PCT Short National Practice Code

Data

Chronic Kidney Disease – QOF Prevalence & Age Specific Prevalence Aged 18+ - 2006/7 – By General Practice

PCT with Lowest CKD

Prevalence In Greater

Manchester

PCT with Highest CKD Prevalence In

Greater Manchester

PCT with Highest CKD Prevalence In

Cheshire &Mersey

PCT with Lowest CKD

Prevalence In Cheshire &

Mersey

PCT with Highest CKD Prevalence In

Cumbria &Lancs

PCT with Lowest CKD

Prevalence In Cumbria &

Lancs

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% BP Last 15 mths % BP 140/85 or less % on ACE/ARB

% BP Last 15 mths 98.5% 98.3% 98.2% 98.2% 98.2% 98.2% 98.2% 98.1% 98.1% 98.0% 97.8%

% BP 140/85 or less 88.1% 87.5% 87.5% 90.1% 87.3% 84.2% 85.5% 86.9% 87.3% 87.1% 86.0%

% on ACE/ARB 83.9% 84.6% 83.3% 86.6% 83.8% 84.4% 83.3% 84.3% 84.2% 85.9% 83.8%

NORTH EAST

NORTH WEST

YORKSHIRE & HUMBE

SOUTH CENTR

AL

EAST OF

ENGLA

WEST MIDLAN

DS

EAST MIDLAN

DS

ENGLAND

SOUTH WEST

SOUTH EAST

COAST

LONDON

Org Level NATIONAL SHA Code (All) SHA Name (All) Old SHA (All) PCT Short (All) National Practice Code (All)

SHA Short

Data

Chronic Kidney Disease – QOF Performance - CKD2: Blood Pressure Measured in the Last 18 Months, CKD3: Blood Pressure 140/85 or Less &

CKD4: Hypertensives on ACE/ARB – QOF Results by SHA

BUTThe denominators For CKD2, CKD3& CKD4 are lower than the no. of

people on the CKD RegisterSEE NEXT SLIDE

SHAs

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

NO

RTH

EA

ST

YOR

KSH

IRE

&H

UM

BER

WE

ST M

IDLA

ND

S

NO

RTH

WES

T

SOU

TH W

EST

EN

GLA

ND

EAS

T M

IDLA

ND

S

SO

UTH

EA

STC

OAS

T

EAST

OF

EN

GLA

ND

SO

UTH

CEN

TRAL

LON

DO

N

BP Measured as % of Register BP 140/85 or less as % of Register ACE/ARB as % of Register

Org Level NATIONAL SHA Code (All) SHA Name (All) Old SHA (All) SHA Short (All) National Practice Code (All)

PCT Short

Data

Chronic Kidney Disease – QOF – CKD2: Blood Pressure Measured in the Last 18 Months, CKD3: Blood Pressure 140/85 or Less & CKD4: Hypertensives on

ACE/ARB – As a % of those on the CKD Register

SHAs

This slide showsthe QOF Results

As a % of People on the CKD Register

QOF Results as reported

QOF Results as a % of peopleon the CKD

Register

Education

and System Redesign

EducationEducation

Iseki et al; Am J Kidney Dis 2006

eGFR and dipstick proteinuria add to predictend stage renal disease

n=95.252, follow-up: 17 years

0.01

0.1

1.0

10

100

1000

eGFR (mL/min)0 30 60 90 120

proteinuria negativeInci

denc

eof

ESR

D p

er 1

000

15

5 4 3 2 1 CKD stages

Iseki et al; Am J Kidney Dis 2006

eGFR and dipstick proteinuria add to predictend stage renal disease

n=95.252, follow-up: 17 years

0.01

0.1

1.0

10

100

1000

proteinuria positive

eGFR (mL/min)0 30 60 90 120

proteinuria negativeInci

denc

eof

ESR

D p

er 1

000

15

5 4 3 2 1 CKD stages

40-80%4CKD 5:The percentage of patients on the CKD register with hypertension and proteinuria who are treated with an angiotensin converting enzyme inhibitor (ACE) or angiotensin receptor blocker (ARB) (unless a contraindication or side effects are recorded)

40-70%11CKD 3Percentage of patients with a BP of 140/85 or less

40-90%6CKD 2Percentage of patients with a record of blood pressure in the previous 15 months

6CKD 1A register of patients aged 18 years and over with CKD (Stage 3-5 CKD)

PaymentStages

Points

The CKD Domain of QOF

April 2008

Impact of eGFR Reporting on Identification of CKD Stage 4

0

5

10

15

20

25

30

1 5 9 13 17 21 25 29 33 37 41 45 49 53 57 61 65 69

Weeks

Num

ber o

f new

pa

tient

s

Lincolnshire PCT

Timely initiation of RRT

Neuropathy/Retinopathy

AcidosisSmoking cessation

Timely access placement/

Transplant Listing

Drug interactionsCalcium Phosphate PTH

Glucose control

Informed choice of RRT/conservative

management

Vascular diseaseAnaemiaBP control

EducationCardiac diseaseMalnutritionACE inhibitors

Prepare for RRTModify co morbiditiesPrevent uraemic complications

Delay progression & reduce CVS Risk

Management of CKD

CKD = chronic kidney disease; RRT = renal replacement therapy

Early Detection of CKD

Timely initiation of RRT

Neuropathy/Retinopathy

AcidosisSmoking cessation

Timely access placement/

Transplant Listing

Drug interactionsCalcium Phosphate PTH

Glucose control

Informed choice of RRT/conservative

management

Vascular diseaseAnaemiaBP control

EducationCardiac diseaseMalnutritionACE inhibitors

Prepare for RRTModify co morbiditiesPrevent uraemic complications

Delay progression & reduce CVS Risk

Management of CKD

CKD = chronic kidney disease; RRT = renal replacement therapy

Early Detection of CKDEarly Detection of CKD

Timely initiation of RRT

Neuropathy/Retinopathy

AcidosisSmoking cessation

Timely access placement/

Transplant Listing

Drug interactionsCalcium Phosphate PTH

Glucose control

Informed choice of RRT/conservative

management

Vascular diseaseAnaemiaBP control

EducationCardiac diseaseMalnutritionACE inhibitors

Prepare for RRTModify co morbiditiesPrevent uraemic complications

Delay progression & reduce CVS Risk

Management of CKD

CKD = chronic kidney disease; RRT = renal replacement therapy

Early Detection of CKDEarly Detection of CKD Think/Report eGFR

Education

Empowerment

Encouragement

Registration

Recall

Review

Individual

Care

Plans

Proteinuria = Risk

The Principles of Managed Kidney Care

Integration

Information Technology

Information

eGFR = % Kidney Function