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Monitoring and Risk Assessment for Renal Patients: GFR, CKD, and Associated Factors

This document outlines the processes and criteria for monitoring renal patients based on their GFR levels and associated risk factors. It includes details on identifying patients at risk for CKD stages 1-5, with a focus on chronic kidney disease coding, blood pressure control, and relevant laboratory tests such as ACR and PCR. The monitoring groups are categorized based on patient data, including coding history and recent GFR results. The inclusion and exclusion criteria for patient data collection are also presented, ensuring comprehensive analysis while adhering to quality assessment protocols.

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Monitoring and Risk Assessment for Renal Patients: GFR, CKD, and Associated Factors

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  1. Testing/Monitoring Renal Group Risk group + ** + No GFR1 Risk - not tested Renal - not tested - ** = will also be captured in group 1 or 3 + Denominators Numerator 1 GFR1 >=60 no RF or RF coded <1 year prior to audit start Patient not at risk Patients who became at risk within last year + Risk– no CKD3-5 - Practice population aged >18 * + - ** + - GFR1<60 and either (GFR2>=60 OR No GFR2) QOF CKD code or coded renal disease for > 1 year Risk– single low GFR Risk Group Renal Group Renal - tested - * + GFR1 and GFR2 <60 Risk – CKD3-5 unregistered * = will also be captured in group 2 Numerator 2 GFR1: Most recent eGFR within the last 12 months GFR2: eGFR prior to GFR1 where > 3months have elapsed between tests and is reported after 1/1/2008 + + lab ACR,/PCR or dipstick proteinuria code in last 12 months Risk - ACR tested Renal – ACR tested - Risk – no ACR Renal – no ACR

  2. Group 1 Coded CKD + Denominator Numerator No GFR1 Coded – no GFR past 2 year - Practice CKD QOF register, age >18 Practice CKD QOF register + GFR1 >=60 Coded – no CKD 3-5 based on last GFR - + No GFR2 OR GFR2>=60 Coded- single GFR GFR1: Most recent eGFR within the last 24 months GFR2: eGFR prior to GFR1 where > 3months have elapsed between tests and is reported after 1/1/2008 - Coded- CKD3-5

  3. Group 2Uncoded with CKD Uncoded patients Denominator Numerator + on QOF CKD register GFR1 <60 and either (No GFR2OR GFR2>=60) + Uncoded– single low GFR Patients with registered CKD 3-5 Practice population aged >18 - - + GFR1 and GFR2 <60 Uncoded patients Uncoded– CKD3-5 GFR1: Most recent eGFR within the last 24 months GFR2: eGFR prior to GFR1 where > 3months have elapsed between tests and is reported after 1/1/2008

  4. Group 3 Early CKD on QOF register or uncoded (group1 and 2) Denominator Numerators CKD captured elsewhere + Practice population aged >18 coded as CKD stage 1/ 2 + - Early – CKD coded + coded with renal disease code Early – non CKD coded

  5. Data extract for all cases (numerators and denominators)

  6. Risk Factors • Risk Factors (RFs): • Hypertension • Diabetes • Gout • IHD, congestive cardiac failure, atrial fibrillation • Cerebrovascular disease • Peripheral arterial disease • Kidney stones • Prostatic hypertrophy • Prescription of lithium last 1 year • Prescription of tacrolimus or cyclosporin last 1 year • Systemic lupus erythamatosis and connective tissue diorders • Agreed Exclusions (as to 29/5/13) • family history – inadequate data available to GPs • NSAIDs – inadequate coding (non-prescription use, prescription but no use) • Haematuria – impossible to interpret • Conditions with renal involvement which will be under the care of a hospital specialist: • sarcoid • amyloid • myeloma • TB

  7. Renal disease codes [This list needs populating from the meeting 29/5/13] Inclusions (agreed 29/5/13): DM with microalbuminuria Systemic disease coded only where nephritis/renal involvement is specified. Alports, Cystic disease, Fabry’s • Proteinuria Codes • This is both a code for proteinuria (as a renal condition) and codes for dipstick positive proteinuria (>1+). [Sally to update] • 467, 4672 to 4675, 4676 to 4678, 467A, 467E, 467H CKD stage 1/2 codes CKD stage 1 without proteinuria Heamaturia codes

  8. Staging Uncoded– CKD3-5 + Denominator Numerator GFR1 >=45 = + Confirmed CKD3-5 CKD 3a Coded- CKD3-5 - Confirmed CKD 3-5 + GFR1 >=30 CKD 3b - + GFR1 >=15 CKD 4 GFR1: Most recent eGFR within the last 24 months - CKD 5

  9. Monitoring This has now been incorporated into the testing algorithm (first slide). It therefore excludes patients with low GFR but without a QOF code or a renal disease code. [agreed 6 July]

  10. BP control Blood Pressure + <=130 systolic and <=80 diastolic Group 2 Uncoded – CKD3-5 - BP subopt + Proteinuric CKD/DM Denominator ACR>=30 (PCR>=50), proteinuria code or diabetes code + BP control = All CKD + Group 1 Coded- CKD3-5 <=130 systolic and <=80 diastolic + - Non-proteinuric CKD Group 3 CKD1/2 - BP subopt Collect: Antihypertensive medication classes Angiotensin Converting Enzyme Angiotensin Receptor Blocker Alpha Blocker Beta Blocker Calcium Channel Blocker Diuretic Aldosterone antagonists Other Antihypertensive Contraindication to ACE/ARB Last systolic BP Last diastolic BP

  11. Referral Denominator Referred or reviewed by nephrology/diabetes specialist in last 24 months All CKD Referred GFR1: Most recent eGFR within the last 12 months GFR2: eGFR prior to GFR1 where > 3months but <15months have elapsed between tests eGFR1<30 (GFR2 – GFR1) >5 and GFR1 is <45ml/min Taking 4 antihypertensive classes (see previous) and last BP>140/90 in last 12 months ACR>=70 (PCR>=100) and no diabetes in last 12 months ACR>=30 (PCR>=50) and heamaturia code in last 12 months Coded genetic kidney disease – see renal disease codes

  12. CV risk No code for IHD, CCF, AF, PVD, cerebrovasc disease CV risk assessment e.g Q risk, framingham CV primary assessed CV risk - primary All CKD collect: statin prescription contraindication to statin prescription exercise advice/weight loss advice stop smoking advice CV risk - secondary additionally collect: aspirin prescription contraindication to aspirin prescription – eg GI bleeding/ulcer warfarin/clopidogrel prescription

  13. CKD care plan Can only be ascertained by patient reported outcomes

  14. Immunisation 1 Influenza immunisation in last 12 months Uncoded– CKD3-5 = + Confirmed CKD3-5 Flu immunised Coded- CKD3-5

  15. Immunisation 2 Hep immune pos neg Uncoded– CKD4-5 Hepatitis HsAb in last 5 years Hepatitis B immunisation in last 5 years yes = + Confirmed CKD4-5 Hep immunised Coded- CKD4-5 unknown Hep unknown Hep non-immunised n.b. this will depend on local practice – will need survey results to interpret these data

  16. Immunisation 3 Uncoded– CKD4-5 Pneumococus immunisation in last 5 years yes = + Confirmed CKD4-5 Pneumo immunised Coded- CKD4-5 Pneumo non-immunised

  17. Hb monitoring Hb sample sent in last 12 months Uncoded– CKD3b-5 = + Confirmed CKD3b-5 Hb monitored Coded- CKD3b-5

  18. BMD Bone metabolism (Ca/PO4/PTH/vit D level) checked in last 12 months Uncoded– CKD4-5 = + Confirmed CKD4-5 BMD monitored Coded- CKD4-5 Collect: Vitamin D preparations (long list) alphacalcidol ergocalciferol calcium tablets + variants sevalemer lanthanum aluminium hydroxide calcium acetate ‘dulwich mixture’/magnesium+calcium

  19. The percentage of people with CKD who are assessed for kidney disease progression and related problems according to their disease stage [*, QS6] • Based on eGFR/urine laboratory results/timing. For CKD 3B percentage that had Hb measured. • The percentage of people with defined indicators for referral who were referred to secondary care [*, QS2] within 3 months of abnormal results • eGFR/urine results and timing, high blood pressure despite 4 antihypertensive drug classes, read-codes for referral and/or renal ultrasound, pop-up box for GPs to fill in if phone or e-mail advice from specialistswas given • The percentage of people with CKD who are assessed for cardiovascular risk [*, QS4] • Management • The percentage of people with CKD who have a current agreed care plan [QS3] by 1 year • read-code on whether patients were informed about their diagnosis (once available), see 4.3. • The percentage of people with CKD who have blood pressures in the NICE recommended target range by 1 year [*, QS5] • Includes proportion of patients on renin-angiotensin blocking drugs according to proteinuria status • The percentage of people with CKD who are treated with statins according to their cardiovascular risk by 1 year [*] • Primary and secondary prevention as per updated NICE lipid guideline (once available) • The percentage of people with CKD who had their medication reviewed whilst acutely unwell • The percentage of people with CKD who were vaccinated for influenza (NICE TA158) • For CKD stages 4 &5 this would also apply to pneumococcal virus and Hepatitis B if seronegative (KDIGO CKD guideline 2013). • The percentage of people with CKD 4&5 who have phosphate and haemoglobin measurements on GP laboratory systems. [*]#

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