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Widening the Circles of Inclusion

Widening the Circles of Inclusion. The National Renal Service Dr Donal O’Donoghue Co-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:

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Widening the Circles of Inclusion

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  1. Widening the Circles of Inclusion The National Renal Service Dr Donal O’Donoghue Co-Chair Renal Advisory Group 4 July 2006

  2. 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

  3. Standard one: A patient-centred service • 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 The National Service Framework for Renal Services

  4. 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) Key Facts (Wanless)

  5. The Epidemic of ESRF

  6. Staging and Prevalence of CKD Adapted from AM J Kidney Dis 2002; 39 (2,Suppl. 1): S17-S31

  7. CKD: A Typical GP Practice of 10000 5 6 15 4 60 Stage of Kidney Disease 30 (GFR) 380 3 60 2 460 90 1

  8. Creating A National Kidney Care Service

  9. 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

  10. Recorded serum creatinine Stage 3–5 CKD NEOERICA: percentage recording of creatinine and prevalence of Stage 3–5 CKD by age Patients (%) 80 70 60 50 40 30 20 10 0 15–24 25–34 35–44 45–54 55–64 65–74 75–84 85+ Age groups

  11. Prevalence of Co-morbidity and Level of GFR GFR <60 ml/min GFR 60 ml/min % DM Any CVD IHD CHF Stroke/TIA PVD

  12. CKD is a Major Health Burden Go et al 2004

  13. Cardiac Kidney Diabetes Anti coagulationAnti arrhythmicsMedical treatment of CHF CKD Stage 4 AnaemiaAcidosisBone diseasePreparation/choice CKD Stage 1, 2, 3EducationBlood pressureSmoking cessationLipid controlMedicines ManagementDiet adviceExercisePsychosocial support Glycaemic control + DM + CHD Complicationseyesfeetkidney CKD Stage 5 HDTpPDMCT RadiologySurgical interventions

  14. Modifiable Risk Factors - Reality • 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

  15. STENO-2 Study 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

  16. The CKD Domain of QOF

  17. 60 50 40 % late referral 30 20 10 0 All Extr Leic York Hope Bristl Notts Newc Sheff Prstn Ports Bangr Mdlsbr StJms Renal Association UK Renal Registry Percentage late referrals (< 3 months) by centre 2002

  18. 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.

  19. 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 % event free survival Pre-emptive 0–6 months 6–12 months 12–24 months 24+ months 100 90 80 70 60 50 40 30 20 0 12 24 36 48 60 72 84 96 108 120 Months post-transplant

  20. Demystifying and Managing Chronic Kidney Disease Education Empowerment Encouragement Knowledge Management CfH Integration Information Technology Information Registration Recall Review eGFR = % Kidney Function

  21. The National Kidney Care Service 158 Local Health Communities 23 Renal Networks 6 Transplant Alliances Widening the Circles of Inclusion

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