Widening the Circles of Inclusion

The National Renal Service

Dr Donal O’DonoghueCo-Chair Renal Advisory Group

4 July 2006

Standard one: A patient-centred service

Aim:

To optimise the role that people with chronic kidney disease can take in the management of their care.

Standard:

All people with chronic kidney disease are to have access to information to make informed decisions and encourage partnership with an agreed care plan.

The National Service Framework for Renal Service

Standard one: A patient-centred service

The National Service Framework for Renal Services

Markers of good practice

• Provision of high quality, culturally appropriate and comprehensive information and education programmes

• Education programmes tailored to the needs of the individual

• Individual care plans, regularly audited, evaluated and reviewed

• Access to a multi-skilled renal team whose members have the appropriate training, experience and skills

Key Facts

CKD

> 5% of population Co-morbidity : 90% HT,

40% CVD, 20% DM SMR 36 in unreferred <

60 years Optimal therapy 30%

Potential savings US $18-60B / 10 years

ESRD

Increasing at 6-8% pa Acute Uraemic Emergencies

22-57% Pre-emptive transplant

listing 3-54% Dialysis survival 1st year 75-

93% Cost £0.4B / year > £0.8B /

year (2002/03) (2010/11)

(Wanless)

UK modality trends 1982 - December 2004

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

Year

Num

ber

of p

atie

nts

PD

Home HDHD

Transplant

The Epidemic of ESRF

Stage Description GFR(ml/min/1.73 m2)

Prevalence (000s)

Prevalence (%)

1Kidney Damage with Normal or ↑ GFR >90 5,900 3.3

2Kidney Damage with

Mild ↓ GFR 60-89 5,300 3.0

3 Moderate ↓ GFR 30-59 7,600 4.3

4 Severe ↓ GFR 15-29 400 0.2

5 Kidney Failure<15

(or dialysis) 300 0.1

Adapted from AM J Kidney Dis 2002; 39 (2,Suppl. 1): S17-S31

Staging and Prevalence of CKD

CKD: A Typical GP Practice of 10000

90460

60

6

380

60

15

30

(GF

R)

(GF

R)

Sta

ge

of

Kid

ney

Dis

ease

Sta

ge

of

Kid

ney

Dis

ease

11

22

33

44

55

Creating A National Kidney Care Service

National Knowledge Base NeLH

National Dataset Renal Dataset

National Clinical & Managerial Standards

NSF, RA, BTS, RR, UKT

National Specification for IT NSF IT Strategy

National Community of Practice www.kidney.nhs.uk

National Template Care Pathway Do Once & Share MAP of Medicine

Modernisation projects in renal services

Modernisation Agency Project : Birmingham, Exeter

Patient View Project: Birmingham, Glasgow, Leeds

Skills for Health Dialysis Project: Birmingham, Leicester, London, Stevenage

Skills for Health Transplant Project: Aberdeen, Canterbury, Cardiff, Gloucester, Hull, London, Newcastle

Learning Sets – Transport: Liverpool, Middlesbrough

Learning Sets – Palliative Care: Birmingham, Manchester

Learning Sets – CKD: Brighton, Leicester

ABPILD Project Posts: Preston, Wolverhampton

Do Once and Share - Leicester

NEOERICA: percentage recording of creatinine and prevalence of Stage 3–5

CKD by age

0

10

20

30

40

50

60

70

80

15–24 25–34 35–44 45–54 55–64 65–74 75–84 85+

Age groups

Patients (%)

Recorded serum creatinine Stage 3–5 CKD

0

5

10

15

20

25

30

35

40

%

GFR 60 ml/min

GFR <60 ml/min

DM CHF Stroke/TIA

PVDAny CVD

IHD

Prevalence of Co-morbidity and Level of GFR

Age-standardised rate of deathfrom any cause (per 100 person-y)16

14

12

10

8

6

4

2

0

0.76 1.08

4.79

11.36

14.14

≥60 45–59 30–44 15–29 <15

Estimated GFR (ml/min/1.73 m2)

No. of events 25,803 11,569 7802 4408 1842

Age-standardised rate of deathfrom any cause (per 100 person-y)16

14

12

10

8

6

4

2

0

0.76 1.08

4.79

11.36

14.14

≥60 45–59 30–44 15–29 <15

Estimated GFR (ml/min/1.73 m2)

No. of events 25,803 11,569 7802 4408 1842

40

35

30

25

20

15

10

5

0

2.11 3.65

11.29

36.60

≥60 45–59 30–44 15–29 <15

Estimated GFR (ml/min/1.73 m2)

No. of events 73,108 34,690 18,580 8809 3824

21.80

Age-standardised rate of cardiovascular events(per 100 person-y)40

35

30

25

20

15

10

5

0

2.11 3.65

11.29

36.60

≥60 45–59 30–44 15–29 <15

Estimated GFR (ml/min/1.73 m2)

No. of events 73,108 34,690 18,580 8809 3824

21.80

Age-standardised rate of cardiovascular events(per 100 person-y)

Go et al 2004

CKD is a Major Health Burden

160

140

120

100

80

60

40

20

0

13.54 17.22

45.26

144.61

Estimated GFR (mL/min/1.73 m2)

No. of events 366,757 106,543 49,177 20,581 11,593

86.75

Age-standardised rate of hospitalizations(per 100 person-y)160

140

120

100

80

60

40

20

0

13.54 17.22

45.26

144.61

Estimated GFR (mL/min/1.73 m2)

No. of events 366,757 106,543 49,177 20,581 11,593

86.75

Age-standardised rate of hospitalizations(per 100 person-y)

CKD Stage 1, 2, 3

EducationBlood pressure

Smoking cessationLipid control

Medicines ManagementDiet adviceExercise

Psychosocial support

CKD Stage 4

AnaemiaAcidosis

Bone diseasePreparation/choice

CKD Stage 5

HDTpPD

MCT

Glycaemic control

Complicationseyesfeet

kidney

RadiologySurgical interventions

Anti coagulationAnti arrhythmics

Medical treatment of CHF

+ DM + CHD

Cardiac Kidney Diabetes

304 pts referred to four renal centres in Canada

Mean GFR 31 ml/min CVD 39%, DM 38%, dyslipidaemia 43%,

smokers 27%, hypertension 80%

– BP > 140/90 35%– ACEI/ARB 65%– Aspirin 27%– Statin 18%

Tonelli M, AJKD 2001;37:484-489

Modifiable Risk Factors - Reality

Relative riskVariable (95% CI) P value

Nephropathy 0.39 (0.17-0.87) 0.003

Retinopathy 0.42 (0.21-0.86) 0.02

Autonomic 0.37 (0.18-0.79) 0.002neuropathy

Peripheral 1.09 (0.54-2.22) 0.66neuropathy

0 0.5 1.0 1.5 2.0 2.5

Intensivetherapybetter

Conventionaltherapybetter

Gaede et al, NEJM 2003;348:383-393

STENO-2 Study

Points PaymentStages

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

6

CKD 2Percentage of patients with a record of blood pressure in the previous 15 months

6 40-90%

CKD 3Percentage of patients with a BP of 140/85 or less

11 40-70%

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

4 40-80%

The CKD Domain of QOF

0

10

20

30

40

50

60

She

ff

Hop

e

Bris

tl

Ext

r

Leic

Yor

k

Prs

tn

Mdl

sbr

Ban

gr

Por

ts

Not

ts

StJ

ms

New

c

All

% la

te r

efe

rra

l

Percentage late referrals (< 3 months) by centre 2002

Late Referral for RRT

> 30% UK patients referred within <4/12 of needing RRT

Higher mortality, morbidity, hospital stay, & cost (~£30k per case), due to poorer clinical state at presentation, lack of vascular access

No possibility of pre-emptive transplantation Propensity score matched

comparison, n=2078

Winkelmayer WC. J Am Soc Nephrol 2003; 14: 486-492.

Pre-emptive & Live Donor Transplantation

Living Donor Kidney Transplants 1995-2003 (UKT)

Unadjusted graft survival in 56,587 recipients of cadaveric transplants by length of dialysis treatment before transplant

155183 179

252270

348 358 372

451 463

0

50

100

150

200

250

300

350

400

450

500

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Graft year

Nu

mb

er o

f g

raft

s

100

90

80

70

60

50

40

30

20

0 12 24 36 48 60 72 84 96 108 120Months post-transplant

% event free survivalPre-emptive

0–6 months

6–12 months

12–24 months

24+ months

Education

Empowerment

Encouragement

Registration

Recall

Review

Knowledge

Management

CfH

Integration

Information Technology

Information

eGFR = % Kidney Function

Demystifying and Managing

Chronic Kidney Disease

The National Kidney Care Service

158 Local Health Communities

23 Renal Networks

6 Transplant Alliances

Widening the Circles of Inclusion