What is CKD?

CKD (Chronic Kidney Disease) is defined as an abnormality of kidney structure or function present for more than 3 months with associated health implications.
Why CKD?

CKD is not being diagnosed enough In South East London (SEL), our CKD registers are half their expected size. Patients who have CKD but are not coded, have double the mortality rate and double the risk of being prescribed nephrotoxic drugs compared to correctly coded patients. CKD is not being managed well enough in South East London.

The CKD project

Our vision is that CKD pathways for those living with stage 3 & Stage 4 CKD and cardiometabolic multi-morbidity (CVD, Diabetes and Obesity), should have better integrated, person-centred and more holistic care, leading to better outcomes for people living with renal-cardiometabolic multi-morbidity.

The project proposal is for a holistic, primary care /community-based clinic approach with a focus on CKD patients with diabetes and hypertension, for whom at least one of those conditions is uncontrolled and where the patient has other aspects that make the management of their care complex (e.g. depression, chronic pain, social circumstances).

Patients from this selected cohort have been identified within each participating GP surgery and have been shortlisted based on medical criteria to take part in the project. Our aim across Bexley is to target 500 patients across the 18month project and increase optimisation for those who are most high risk.

Patients will be offered a bespoke programme with follow up appointments, screening, multi-agency clinics and medicine optimisation, they are also offered a referral to a social prescriber to support with lifestyle management and long term health changes such as diet, exercise, smoking cessation and mental health support.

Our targets for each patient on the project:
• Maintained EGFR
• Improved patient activation score
• Improvement in annual HbA1c, U&E, ACR, Lipid profile or BP
• Patient feedback

The impact of CKD

CKD is associated with reduced life expectancy, even at early stages.
CKD is a stronger risk factor for cardiovascular events than diabetes
End-stage kidney disease has worse survival rates than colorectal and breast cancer.
Treatment and improved outcomes
There is better treatment now available for CKD.
Dapagliflozin reduces all mortality by 30% in patients with CKD, and there is a 37% reduction in significant renal or cardiovascular morbidity. By optimising treatment this may delay patient’s progression to end-stage kidney disease by 15 years.

The availability of peer support in the community enables the patient to connect with local resources and make positive lifestyle changes.

If you wish to hear more about this project, please email us on bhnc.kidneycare@nhs.net