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Living with a health condition

Improving CKD care

Improving Chronic Kidney Disease (CKD) Care 

Hounslow CKD

Renal Services at Imperial College Healthcare NHS Trust have - together with Hounslow and Hammersmith & Fulham Clinical Commissioning Groups (CCGs) - developed a shared care pathway to manage the significant number of patients who have non-progressive renal impairment and do not require specialist input from the renal team at our secondary centre.

This Shared Care Pathway allows community teams an opportunity to increase their knowledge and expertise in kidney disease and ensure management of CKD is consistent with NICE CKD guidance amongst primary care teams across the region. By allowing community teams to care for their stable CKD patients, specialist renal teams in secondary care will be able to focus on more complex or active renal impairment. Together with the Department of Medicine for the Elderly, an additional guideline has been drawn up to help manage the frail patient with CKD in primary care. 

Together with the Department of Medicine for the Elderly, an additional guideline has been drawn up to help manage the frail patient with CKD in primary care.

Ultimately this quality initiative will avoid unnecessary hospital appointments for specialist opinion and allow patients to be seen closer to their homes by a community team that has been empowered to manage kidney disease appropriately and safely.

Which patients will be involved in the shared care pathway?

Clinical judgment will be used to determine whether a patient is appropriate for discharge back to primary care. An experienced Consultant Nephrologist will use the criteria below to assess whether to utilise the pathway and discharge to community care:

  • Stable CKD stage 3, defined by < 5ml/min/1.73m2 change within a period of 6-12months, using all available data; 
  • Urine PCR < 100 mg/mmol;
  • Unlikely to require immunosuppression or other specialised renal intervention

What are the advantages for our patients?

The pathway ensures the following patient benefits:

  • Reduce inconsistencies in care and ensure management is delivered in accordance with NICE clinical guideline 182;
  • Seamless transition to care within community services; 
  • Increased individual patient engagement with their CKD management; 
  • Reduced requirement to travel to centrally located hospitals as clinical care is provided in community practices nearer home.


The renal service plan to carry out an audit of the discharged patient 12 months after discharge, from autumn 2016, to assess the quality of care and frequency of clinical monitoring the patient has received within the community, and to evaluate the proportion of patients continuing to be managed in primary care at this time-point.

How are community teams being supported to deliver this service?

Education workshops:

Since initiation in April 2015 clinicians from Imperial College Healthcare NHS Trust have run a number of highly interactive, practical education sessions aimed at improving understanding of the management of CKD and criteria for referral. These sessions provide the opportunity to network, building strong links between primary and secondary care teams. Attendees from the community teams are also eligible to collect Continuous Professional Development (CPD) points for these sessions.

An e-advice service

An email advice service has been set up to provide timely responses to specific queries about management and referral decisions for their patients with CKD.
The email address is ICHC-tr.ckdadvice-imperial@nhs.net

This mailbox is manned by our senior nephrology consultants who will be able to share their valuable expertise with community teams.


These have been developed by the clinical team at Imperial College Healthcare NHS Trust following a number of education workshops and address the most common concerns for GPs and Practice Nurses regarding CKD3 management.

How do I provide feedback on the service?

We are keen to get feedback from primary care staff on the discharge information we are sending to the patient’s GP surgery.

Feedback can be directed to Dr Andrew Frankel, Nephrologist via email: a.frankel@imperial.ac.uk.

Patients and their carers can provide feedback on the service they have received from the Trust’s renal service by contacting the patient advice and liaison service (PALS) on 020 3313 0088 (Charing Cross, Hammersmith and Queen Charlotte’s and Chelsea hospitals), or 020 3312 7777 (St Mary’s and Western Eye hospitals). They can also email PALS at pals@imperial.nhs.uk. The PALS team will listen to their concerns, suggestions or queries.

Where can I find out more?

We plan to keep you updated through regular updates on our GP bulletin. If you would like to know more, please contact Dr Andrew Frankel, Consultant Nephrologist via email: a.frankel@imperial.ac.uk.

For a list of contact numbers for our nephrology clinic's see here.