Chronic Kidney Disease (CKD)

CDRC has developed a range of clinically validated resources to support the identification, diagnosis, and ongoing management of patients with Chronic Kidney Disease (CKD) within primary care. These resources are designed to help practices identify patients who may have undiagnosed CKD, improve the recording and coding of CKD, support compliance with national guidance and Quality and Outcomes Framework (QOF) requirements, and facilitate proactive management of patients at risk of disease progression.

Available resources include patient identification reports, clinical dashboards, recall tools, and decision-support resources that enable practices to monitor key indicators such as eGFR and uACR testing, review coding accuracy, and identify patients who require further assessment or intervention. Specific reports folders are also available to support the Are You Taking The Pee? Campaign and the SPOT CKD Programme.

Accessing CDRC resources on SystmOne

To access the below resources you will need to be a member of the DCS group on SystmOne. To do this, please follow the instructions on the CDRC SystmOne Access webpage.

AKI & CKD Quality Improvement Resources

CDRC’s AKI & CKD Reports (Searches) support the identification of patients at high risk of an AKI on specific medications & with the identification and management of patients with potential and confirmed CKD.

These reports are found in the CDRC Quality > Renal folder.

Our Acute Kidney Injury (AKI) Prevention reports will support practices by identifying patients with a high risk of an AKI, or coded with an AKI in the last 3 years, on specific medication courses that you may with to alter.

Our CKD reports will support practices with the identification and management of patients with potential and confirmed CKD.

The CKD Casefinding reports will support the identification of patients with potential CKD, based on their eGFR and ACR blood tests.

These reports identify patients who have had an isolated eGFR <60 over 4 months ago (consider repeating their eGFR), or who have had two eGFR <60 results 3 months apart (review the patients record and consider a CKD diagnosis, results may indicate an AKI and so it is important to review their clinical record prior to diagnosis).

While our CKD Management reports incorporate:

• Coding Issues: Patients whose latest eGFR and/or ACR do not reflect their current CKD diagnosis
• Management: Patients whose blood pressure (BP) is not controlled or their BP measurement is overdue
• Monitoring: Patients with overdue monitoring requirements
• Intervention: Patients to consider for medication interventions

The CKD Dashboard – CDRC can be accessed using the ‘Search features’ search bar located in the lower left-hand corner of the SystmOne screen, type in ‘Launch Visualisation’ and select the returned feature.

This will open the ‘Select Visualisation’ page where you can search for, and select, the “CKD Dashboard – CDRC” visualisation.

The CKD Dashboard – CDRC provides an overview of your practice’s CKD prevalence and diagnosis rates, helping to identify areas for quality improvement and case finding.Additional information can be viewed by expanding the relevant sections using the drop-down arrows next to each category.The dashboard allows users to explore data in greater detail, supporting the identification of patients who may require further review, investigation, or coding optimisation.

The CKD Dashboard – CDRC Visualisation links to specific CKD Reports, you can view the patient list of these reports by clicking on the red jigsaw piece.

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