PrescQIPP

Chronic Kidney Disease Case Finding and Management (2025)

South Dales PCN 

Project summary

Background

Chronic Kidney Disease (CKD) is defined by NICE as a reduction in kidney function or structural damage (or both) present for 3 months or more with associated health implications. It is estimated that 1 in 10 of the UK population have CKD with a third of those thought to be undiagnosed. CKD is a major risk factor for cardiovascular disease. Early identification of patients with CKD can help to optimise their care and reduce their risk of cardiovascular disease, hospital admissions and overall cost for the NHS. Effective coding is key to identifying patients with CKD, managing their blood pressure and reducing albuminuria. As a PCN, we identified coding and management of CKD as an area requiring improvement.

Description of work

All patients with 2 consecutive eGFRs <60ml/min at least 3 months apart who were not coded as having CKD on System 1 were reviewed. Urine ACR samples were requested for these patients to confirm CKD diagnosis and correct coding added if appropriate. Patient's records were reviewed to check whether blood pressure was well controlled, whether statins were prescribed or had been offered and whether management of raised ACR was required. Patients were then sent a CKD patient information letter informing them of the diagnosis and to provide some self-help advice. Patients who needed raised ACR managing, review of blood pressure control, offer of a statin or SGLT2i were booked in for a medication review to discuss any changes that were required. Practice staff education and training was also provided by the pharmacy team on CKD identification, diagnosis and management at a clinical meeting. PCN staff also completed the Primary Care Cardiovascular Society CKD module training. 

Outcomes

  • CKD register was updated. 
  • CKD patients are better managed in line with current guidelines to reduce long term risk of CVD and progression of CKD.
  • Better staff education regarding management of CKD through training hopefully leading to a reduced number of missed diagnoses in the future. 
  • Patients are now well informed regarding their CKD diagnosis. 
  • QoF targets for cholesterol were met as new patients added to the CKD register were offered statins.