ASSIST-CKD is a method of monitoring the blood test results of people with chronic kidney disease and alerting GPs if their condition worsens. This means that people can be referred promptly and given the right treatment at the right time.

Why was this work needed?

Nearly 2 million people in the UK have been diagnosed with moderate-severe chronic kidney disease (CKD), although it is estimated that a further 1 million may remain undiagnosed. By ensuring that those with CKD are referred for the right treatment in the right care setting at the right time, the need for dialysis or a kidney transplant could be delayed or even totally avoided.

What happened?

ASSIST-CKD aims to identify people who have the greatest risk of their CKD worsening and promptly refer them for the appropriate treatment. It builds on a successful pilot at the Heart of England Foundation Trust (HEFT) in Birmingham.

Participating areas use software to map data from routine blood tests (eGFR), which allows them to monitor how someone’s kidneys are functioning over a period of time. If a person’s condition is worsening, their GP will be sent a report to tell them. Equally, a person with a stable condition can be confidently discharged to their GP, knowing that their blood test results are still being collected and monitored over time.

What were the benefits?

HEFT now has the lowest number of people being referred for dialysis at a late stage in their disease. This is particularly important because late referral can lead to poorer outcomes.

This programme was popular with GPs in the West Midlands, where it was piloted, with 74% saying they found it useful and 41% changing their management of patients as a result.

Hopefully these benefits will be seen more widely across the country, as ASSIST-CKD is rolled out to more participating centres.

What type of data was involved?

Individual’s blood test results are monitored over time.

Patient data is being used to support individual care.

Who funded and collaborated on this work?

Kidney Research UK leads this project, supported by the Health Foundation.

Where can I go for more information?

Identifying and monitoring people at greatest risk of progressive chronic kidney disease (CKD)