Abstract
Background: Approximately 6% of the UK’s population live with chronic kidney disease (CKD). Affected patients risk progression to end-stage renal disease (ESRD) and are more likely to develop cardiovascular disease. CKD progression can be reduced through blood pressure control and anti-proteinuric therapies, however identifying at-risk patients in Primary Care is challenging. Through interface of Primary and Secondary Care services, we developed a guideline to optimise the management of at-risk CKD patients.
Methods: The project was developed collaboratively between the Ulster Hospital and The Priory and Springhill Surgeries in County Down, with the support of Interface Clinical Services (employed by AztraZeneca). A Primary Care CKD guideline was produced to steer the intervention. Framework was built upon existing Primary Care software to extract data and identify appropriate patients. The surgeries’ registers of 14,525 patients were vetted. Inclusion criteria included; a diagnosis of CKD, moderate or severe proteinuria (A2 or A3), or evidence of an eGFR <60mls/min with co-existent diabetes mellitus type 2. High risk patients were assigned to review cohorts and offered an Interface led consultation. Baseline data was collected on a range of metrics including blood pressure, eGFR and urine albumin/creatinine ratio (uACR).
Results: 905 patients met the inclusion criteria (6% of the population), falling to 877 after exclusion criteria were applied. Applying KDIGO criteria, 450 (50%) were defined as moderate risk, 86 (10%) high risk and 69 (8%) very high risk. 33% did not have a uACR recorded to determine risk. 28% were calculated to have a 5-year ESRD risk of >5% while 65 patients (7%) met additional criteria for referral to Secondary Care.
Co-morbidity was common with hypertension in 38%, cardiovascular diseases in 31% and heart failure in 18%. Review of baseline prescribing found 447 patients (49%) were already prescribing a RAAS inhibitor, 320 with diabetic kidney disease (DKD) and 127 with non-diabetic CKD. SGLT2 inhibitors were prescribed for 135 patients (22%) with DKD, but only 14 patients (5%) with non-diabetic CKD.
212 patients were assigned review cohorts. The remaining 665 were assigned practice follow-up. 137 (65%) responded to correspondence and were offered a consultation. 82 patients (39%) were reviewed across 6 clinics. 57 patients (70%) received a pharmacological intervention, while 100% received a non-pharmacological intervention. RAAS inhibitors were initiated or optimised in 19 (23%). SGLT2 inhibitors were commenced in 45 (55%). 70% of patients with DKD received an evidence-based pharmacological intervention related to RAAS and/or SGLT2 inhibition.
Conclusions: This work offers a glimpse into the current state of CKD management in Primary Care and demonstrates the potential of collaborative working. The population was co-morbid, highlighting the complementary benefits of optimising CKD management. The framework was built upon software already in place in Primary Care and our results were achieved within 4 months, highlighting the potential to trial the intervention in other settings.
Disclosures: The project was supported by the CKD Medicines Optimisation Review Service, a non-promotional medical service funded by AstraZeneca and delivered by a team of pharmacists employed by Interface Clinical Services, working on behalf of AstraZeneca.