Chronic kidney disease (CKD) is defined as a reduction in kidney function or structural damage (or both) present for more than 3 months [1]. It is associated with multiple complications such as acute kidney injury, endstage kidney disease (ESKD), and cardiovascular diseases. CKD is not a standalone condition that occurs in a patient; its aetiology stems from a host of other chronic diseases a patient may suffer from such as diabetes mellitus and hypertension [2]. Furthermore, there are several environmental and societal factors which can catalyse CKD and associated conditions. This includes demographics, health inequalities, genetic, cultural and biological contributors [3]. Combined with these comorbidities, CKD significantly contributes to increased mortality in patients. Therefore, the health implications to the health service for treating CKD appropriately are manifest [4]. Indeed, according to a recent report by Kidney Research UK, in 2023 kidney diseases account for approximately 3.2% of total NHS spending, representing £6.4bn. With CKD affecting more than 10% of the UK population, this figure is increasing proportionately with average population age [5].

For the optimal management of CKD there should be an aim to move away from treating standalone cardiovascular, kidney or metabolic pathologies and instead optimise treatment of these individuals in context of their multiple morbidities [6]. CKD is diagnosed by measuring the Estimated Glomerular Filtration rate (eGFR) and other factors such as proteinuria and haematuria. It is classified in 5 stages based on the eGFR and Albumin Creatine ratio (ACR) [7].

CKD Stage 1: eGFR > 90 ml/min/1.73m2,

CKD Stage 2: eGFR is 60-89 ml/min/1.73m2,

CKD Stage 3a: eGFR is 45-59 ml/min/1.73m2,

CKD Stage 3b: eGFR is 30-44 ml/min/1.73m2,

CKD Stage 4: eGFR is 15-29 ml/min/1.73m2,

CKD stage 5: eGFR is < 15 ml/min/1.73m2.

Each of the above 5 stages is further categorised by ACR levels with results given as a stage from 1 to 3:

A1 – an ACR of less than 3 mg/mmol.

A2 – an ACR of 3 to 30 mg/mmol.

A3 – an ACR of more than 30 mg/mmol.

The incidence and prevalence of CKD varies depending on the population studied, including ethnic group and socio-economic class. Kidney Research UK estimates that 7.2 million people currently have CKD in stages 1–5, equating to more than 10% of the population [8]. Public Health England produced a CKD prevalence model in 2014 using The Health Survey for England (HSE) 2010 report to show a clear association between increasing age and higher CKD stage 3a-5 prevalence [9]. It is likely that prevalence is rising as the population is ageing and several CKD risk factors such as obesity, type 2 diabetes, and hypertension are also increasingly common.

Currently, CKD is managed via a combination of tighter blood pressure (BP) control, lipid management, and lifestyle interventions (such as dietary advice, smoke cessation, and exercise). Medical treatment is usually administered in the form of Angiotensin-Converting Enzyme inhibitors (ACEi) or Angiotensin Receptor Blockers (ARBs) for cardiovascular and renal protection, and BP control, along with a statin for lipid control and reduction of cardiovascular disease risk [10]. In 2020, the DapaCKD study by Heerspink, et al. demonstrated positive outcomes with the use of Dapagliflozin in patients with CKD (irrespective of diabetes status). The study demonstrated “the risk of a composite of a sustained decline in the estimated GFR of at least 50%,’ and ‘end-stage kidney disease, or death from renal or cardiovascular causes significantly lower with dapagliflozin than with placebo” [11]. Based on this, in November 2021, the National Institute for Health and Care Excellence (NICE) recommended the use of Dapagliflozin for people with CKD and in March 2022 released Technology appraisal guidance (TA775). This provided evidence-based recommendations on its use [12]. Optimising the management of chronic kidney disease may improve patient outcomes, such as slowing the progression of the disease and reducing the risk of developing complications, such as cardiovascular disease [13].

Kidney Care UK estimate that around 3.5 m million people in the UK have the later stages of CKD (stages 3–5) with 30,000 people on dialysis. This number is rising as it is estimated that over 20 people develop kidney disease each day, with around 7,000 people waiting for a kidney transplant [14].

Complications from CKD arise from several well-known and newly understood mechanisms. Improvements in the understanding of these mechanisms have resulted in better optimisation of older therapies as well as the utilisation of novel treatments. These mechanisms include, increased neuro-hormonal activation, oxidative stress, inflammation, and platelet dysfunction, as well as phosphate retention leading to vascular calcification. In particular areas of neuro-hormonal activation, platelet dysfunction and inflammation have been increasingly studied and understood.

For patients with chronic heart failure as well as CKD, ACEi, and ARB therapies have shown inconsistent responses and bathe use of Angiotensin receptor and Neprilyn inhibitors have provided added benefits in by counteracting neurohormonal mechaniosms and reducing inflammation. The PARADIGM-HF and the PARAGON-HF studies both show the benefit of this new class of drifts on cardiovascular deaths and heart failure admissions.

Furthermore, SGLT2 inhibitors have been shown to have benefit from reducing platelet activation and enhancing sodium excretion. These effects have also translated to better cardiovascular outcomes and NICE guidelines have reflected on these benefits by including them in CKD management guidelines.

Glucan like peptide inhibitors as well as novel dual inhibitor drugs, such as tirzepatide, have also shown beneficial cardiovascular outcomes in patients with CKD.

Newer mineralocorticoid receptors antagonists, such as finerenone, have more beneficial effects as well as better adverse effect profiles than the older spironolactone. Given the advances in CKD management, as well as better cardiovascular outcomes, it is important that patients with CKD are managed by primary care teams with good support from Nephrology specialists as part of a MDT so that optimal therapies can be utilised early and monitored carefully in primary care [15].

It therefore follows that there may be a positive ripple effect from tackling CKD with optimising therapy as it may also have an impact on the cost burden of cardiovascular diseases and KRT for the NHS [16]. The 2021 UK Renal Registry Annual Report highlighted an increasing number of people on KRT, growing from 68,000 in 2020 to 69,500 in 2021 [17]. Furthermore, uncertainty surrounding appropriate referrals to secondary care is a recognised problem in healthcare potentially due to a clinician’s lack of confidence in their expertise about the most appropriate type of healthcare [18].

Given the significance of appropriate CKD management, the Willows Health CKD taskforce set out a novel quality improvement (QI) initiative designed to utilise multidisciplinary team (MDT) interventions and integrated digital systems aimed at improving kidney health for all. The novelty of this project lies within the combined use of educational outreach from secondary care consultants and the development of a series of decision-support and clinical management tools within the PCNs clinical management system, SystmOne to optimise CKD management. This may provide a replicable method of quality improvement for other PCNs.

This quality improvement project sought to improve CKD management and health outcomes, reduce unnecessary referrals to secondary care, and promote integration, maximising productivity and value for money across the healthcare system. Medicines optimisation in patients with CKD was another aim in this project, to improve patient health and outcomes.

This paper presents the results of a quality improvement project aimed at optimising the management of chronic kidney disease in primary care. The service redesign method, and participants in this quality improvement project will be outlined. Additionally, the development of the integrated digital system for this service redesign will be delineated. Furthermore, the impact of this service redesign, particularly in relation to referrals to secondary care, will be analysed and discussed.