Wednesday, 30 January 2008

January update 2008

The Prime Minister put kidney disease at the centre of the vascular triad of coronary heart disease, chronic kidney disease and diabetes in his first major speech on the NHS. Listen to Gordon Brown’s 7 January interview on Radio 4 here (8.00-8.30 slot). The PM also announced plans to introduce abdominal aortic aneurism screening as part of the focus on vascular control.

The following weekend the debate about presumed consent, backed by the Chief Medical Officer, Sir Liam Donaldson in his summer report on the state of the nations health, resurfaced in the run up to the publication of the Donor Task Force report “Organs for Transplants” that was accepted in full by the government.

This unprecedented focus on the kidney and kidney disease follows hard on the heels of inclusion of dialysis capacity as a key priority in the operating framework of the NHS for 2008. Timely initiation of renal replacement therapy remains a concern for many patients in many units. Our systems do not always ensure pre-emptive transplant listing, choice of the full range of dialysis options or community based dialysis. Delays in starting dialysis and even talk of the clinically unacceptable practice of twice weekly haemodialysis, is all too common. Building sufficient dialysis capacity remains a key goal for the coming year. I am working closely with Strategic Health Authorities on this mater and reviewing planning assumptions with Regional Commissioning Groups and networks.

Progress on detection of early kidney disease continues. The visibility of CKD brought about by the introduction of systematic estimated GFR reporting has resulted in 3% of the adult population being identified and placed on kidney disease registers in the first year of operation. We know from recent studies that the expected prevalence is closer to 8% and that practice level information shows a large variation which can only be explained by under detection. General practice has done extremely well from a standing start. The data now identifies the practices and PCTs where support and education are most needed.

So is early identification adding value? That’s actually a complex question – yes registration is the first component of a chronic disease management programme but “disease labelling” carries its own risk. Benefits accrue from interventions that alter the natural history, reduce risks or improved experience of a condition – in kidney disease achieving good blood pressure control is perhaps the most important surrogate for better outcomes. The overwhelming majority of those on primary care CKD registers, greater than 95%, are being recalled to have their blood pressures checked but only in about 60% of people with kidney disease is the achieved blood pressure less than 140/85. The clinical target is of course less than 130/80 so we have a way to go!

Progress on other fronts includes introduction of 18 week pathways for CKD and live donor transplantation, publication of the action learning sets reports on the year before replacement therapy, transitional care between paediatric and adult services and acute kidney injury, establishment of working groups on dialysis away from base unit and supportive and palliative care.

The recent announcements and current work streams provides a platform on which to make further progress over the coming 12 months. If you would like to get involved in any of these initiatives please do contact me at donal.o’