Part of: Ill Health and Disability

Related to: Ageing Population, [[Health Checks]], Alcohol, Diabetes, Coronary Heart Disease, Heart Failure, Hypertension, Major Causes of Mortality, Medicines Management and Optimisation, Healthy Weight, Stroke

Key Facts:

  • There were 5,232 people aged 18 years and over in 2012/13 (financial year) registered with chronic kidney disease in GP practises in Bath and North East Somerset, a rate of 3.3% of the registered 18 years and over population.
  • The rate of chronic kidney disease (ages 18+) in Bath and North East Somerset is lower than England
  • The rate of emergency admissions for those with acute kidney injury in Bath and North East Somerset CCG is 7.2, this compares with 6.7 nationally

Chronic kidney disease (CKD) is a long-term condition where the kidneys do not work effectively.This is most often caused by the strain placed on the kidneys by other conditions, most commonly diabetes and high blood pressure. CKD does not usually cause symptoms until reaching an advanced stage. However, it is usually detected at earlier stages by blood and urine tests. 1

There is no cure for chronic kidney disease, although treatment can slow or halt the progression of the disease and can prevent other serious conditions developing.

People with CKD are known to have an increased risk of a stroke or heart attack because of changes that occur to the circulation. In some people, CKD may cause kidney failure, also known as established renal failure (ERF), end-stage kidney disease, or acute kidney injury (AKI). In order to survive, these people may need to dialysis.

What does the data say?

Chronic kidney disease is common and mainly associated with ageing. The older you get, the more likely you are to have some degree of kidney disease. 2

It is estimated that about one in five men and one in four women between the ages of 65 and 74 has some degree of CKD. 3

CKD is more common in people of south Asian origin (those from India, Bangladesh, Sri Lanka and Pakistan) and black people than the general population. The reasons for this include higher rates of diabetes in south Asian people and higher rates of high blood pressure in African or Caribbean people. 4

CKD prevalence shows a socio-economic gradient with the most deprived populations at higher risk compared to the general population. 5

Cardiovascular disease, hypertension and diabetes are common risk factors for CKD, and they often co-exist with other factors such as obesity. 6

Across England there has been an increase in the number of people on renal replacement therapy over time. 7

The cost of chronic kidney disease 8

It is estimated that the NHS in England spent £1.45 billion on CKD in 2009/10, equivalent to £1 in every £77 of NHS expenditure. This estimate covers both direct (renal care and prescribing to reduce disease progression) and indirect (e.g. treatment of non-renal issues such as strokes in people with CKD) costs.

Bath and North East Somerset

There were 5,232 people aged 18 years and over in 2012/13 (financial year) registered with chronic kidney disease in GP practises in Bath and North East Somerset.* 9

For the period 2008/09  to 2012/13 (financial years) the prevalence of chronic kidney disease in those 18 years and over in B&NES and England has remained fairly stable, between 3.5%and 3.3%. in B&NES and 4.1 and 4.3% in England. Thus, the prevalence of chronic kidney disease (ages 18+) in B&NES has been lower than England. In 2012/13 the rate was 3.3% in B&NES, compared to 4.3% in England.* fn] HSCIC (Health and Social Care Information Centre) (2013) Quality and Outcome Framwork 2012-2013 Practice level, http://www.hscic.gov.uk/catalogue/PUB12262 

chronic_kidney_disease_rates_in_bnes_and_england_gp_populations_2008-2013_line_graph

Figure 1: Chronic Kidney Disease prevalence (ages 18+) in B&NES and England GP 18 years + registered populations (2008/09 – 2012/13 financial years)* 10

*It is important to note that the above rates are based on the GP registered population of Bath and North East Somerset and so some of these people may not be residents of Bath North East Somerset. Nevertheless, the vast majority of people will be registered with a GP in their county of residence.

For more up to date prevalence figures for chronic kidney disease recorded as part of the NHS Quality and Outcomes Framework (QOF), see the Ill Health and Disability section. 

It is also estimated that there are 5,260 people with CKD in Bath and North East Somerset’s Clinical Commissioning Group (CCGs) who are currently undiagnosed. CCGs represent new health geographies, built up from individual GP practices. The total population of Bath & NE Somerset CCG is 197,200 and 158,400 of these people are aged 18 years and older. 11

The rate of chronic kidney disease for those 18 years and over in the GP registered population in Bath and North East Somerset gradually increased between 2008-2011 from 3.4% to 3.6%, but then returned to its rate of 3.4% in 2011-12.* 12

The rates of chronic kidney disease (18 years +) in the registered GP population of the South West as a whole and England have increased slightly between 2008-2012, 4.5%-4.8% and 4.1-4.3% respectively. Thus, the rate of chronic kidney disease (ages 18+) in Bath and North East Somerset is significantly lower than the South West and England, with the South West experiencing the highest rates.* 13

*It is important to note that the above rates are based on the GP registered population of Bath and North East Somerset and so some of these people may not be residents of Bath North East Somerset. Nevertheless, the vast majority of people will be registered with a GP in their county of residence.

The rate of admissions for those with acute kidney injury per 1,000 of emergency admissions in Bath and North East Somerset Clinical Commissioning Group is 7.2, this compares with 6.7 nationally.

** It is worth bearing in mind that admission rates are based on inpatient spells where AKI appears as the primary diagnose within one hospital episode. Also that this data relies on the completeness of AKI coding within Hospital Episode Statistics (HES) and is likely to represent an underestimate of the true number, as it is known that AKI tends to be under recorded.

The median length of stay for those admitted to hospital with acute kidney injury in Bath and North East Somerset Clinical Commissioning Group is 8 days, compared to 9 days nationally.**

The cost of chronic kidney disease 14

It is estimated that the annual primary care expenditure directly attributable to CKD in Bath and North East Somerset CCG is £955,996 and the total direct cost of CKD in primary and secondary care is estimated to be £4,262,471.

Are we meeting the needs? 15

The three kidney centres identified as closest to Bath & NE Somerset CCG are Southmead Hospital, Oxford Radcliffe Hospital and Dorset County Hospital.

Bath and North East Somerset Clinical Commissioning Group (CCG) improved to some degree across seven of the eleven chronic kidney disease and CKD-associated (QOF) clinical achievement indicators between 2010/11 and 2011/12. There is a wide variation in the achievement of these indicators at practice level within the CCG.

QOF Chronic Kidney Disease Clinical Indicators

Bath and North East Somerset CCG

England

CKD2 - % of patients on the CKD register whose notes have a record of blood pressure in the previous 15 months.

97.5%

97.2%

CKD3 -% of patients on the CKD register for whom the last blood pressure reading, measured in the previous 15 months, is 140/85 or less.

72.5%

75.1%

CKD5 -% of patients on the CKD register with hypertension and proteinuria who are treated with anangiotensin converting enzyme inhibitor (ACE-I) or angiotensin receptor blocker (ARB) unless a contraindication or side effects are recorded.

91.3%

89.5%

CKD6 - % of patients on the CKD register whose notes have a record of urine albumin: creatinine ratio (or protein: creatinine ration) test in the previous 15 months.

86.5%

82.2%

Table 1: Present achievement against QOF CKD clinical indicators for Bath and North East Somerset CCG and England (2011/12) 16

It is worth bearing in mind that the CKD QOF (GP) registers do not include the undiagnosed and if these were added the QOF CKD clinical indicators achievement levels would be lower.

The NCEPOD report ‘Acute Kidney Injury: Adding Insult to Injury' highlights the process of care of patients who died in hospital with a primary diagnosis of acute kidney injury and takes a critical look at areas where the care of patients might have been improved. The AKI Capacity Survey (England and Wales) concluded that ‘there is much variation in the model of nephrology AKI management across England.’ 17

Despite AKI representing a significant cause of preventable patient harm, the exact incidence of AKI in hospitals is unclear, as is the quality of care such patients receive. 18

A survey of acute trusts at the end of 2011 showed many had or were about to develop alert systems to identify patients with biochemical results consistent with AKI. Building on this, NHS Kidney Care is working in collaboration with 47 acute trusts in England to establish a mechanism for collecting and comparing this information. 19

Mortality from kidney disease 20

There are no mortality statistics for kidney disease available at Clinical Commissioning Group (CCG) level and the national mortality statistics currently available are under review as they are thought to underestimate the true number of deaths which are attributed to kidney disease.

It is anticipated that as CCG geographical boundary development improves, CCG level mortality statistics will become possible.

What can we realistically change? 21

In Manchester and Leicestershire, two projects have investigated under-registration of those with chronic kidney disease and developed tools and resources to help practices find and manage patients. Over the next three years this approach will be offered nationally.

Cardiovascular disease, hypertension and diabetes are common risk factors for CKD, and they often co-exist with other factors such as obesity. If these risk factors are well managed the prevalence of CKD will decrease.

It is clinically advantageous for people with End Stage Renal Disease to be referred to kidney services early to allow time for consideration of the different treatment options and for kidney disease and any related complications to be managed adequately before Renal Replacement Therapy (RRT) is commenced. Late referral may result in increased morbidity and mortality. It is estimated that 90 days is sufficient time to receive optimum treatment and preparation by the kidney care team prior to starting RRT.

The NICE Kidney Disease Quality Standards suggest that people should have the option to choose where they receive dialysis, but ideally this should be from home.

National Institute for Health and Clinical Excellence (NICE)(2011-2013) guidance