In 2023, Kidney Research UK labelled kidney disease a public health emergency in need or urgent attention. The ASSIST-CKD project aimed to monitor blood test results of people with chronic kidney disease and alert GPs if their condition worsens. This allows people to be referred promptly and given the right treatment at the right time.

Why was this work needed?

In the UK, the population of people living with chronic kidney disease (CKD) is estimated to be 7.2 million – more than 10% of the population – and this is expected to increase with an ageing population and worsening health and economic inequalities. By ensuring that those with CKD are referred for the right treatment in the right care setting at the right time, the need for the most extreme treatments such as dialysis or a kidney transplant could be delayed or even totally avoided.

What happened?

ASSIST-CKD aimed to identify people who have the greatest risk of their CKD worsening and promptly refer them for the appropriate treatment, building on a successful pilot at the Heart of England Foundation Trust (HEFT) in Birmingham. Participating project sites included twenty renal units and pathology labs and their surrounding GP practices, covering England, Scotland, Wales and Northern Ireland.

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

What were the benefits?

The original HEFT pilot demonstrated that the programme resulted in 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. The programme was popular with GPs, with 74% saying they found it useful and 41% changing their management of patients as a result.

ASSIST-CKD was then rolled out to further sites for further testing and software development. The project has now completed, with the methodology and tools available to any site who wishes to adopt them. The benefits observed by participating sites included GP’s being prompted to re-look at patient notes, review medications, and refer to renal teams. This has led to improved awareness of CKD, greater understanding of routine blood tests by GPs, improved management of kidney function medicines, and involvement of patients in understanding their condition.

What type of data was involved?

Individual’s blood test results are monitored over time by a software which extracts that data from pathology labs. The graphs that are generated are then accessible to lab staff and renal healthcare professionals who have been given training. When necessary, the graph is shared with a patient’s GP to alert them to perform a kidney function review. The graph can then also be shared and discussed with the patient directly.

As the blood test results were being used to support individual care, direct consent from patients was not required.

Who funded and collaborated on this work?

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

Where can I go for more information?


Kidney Research UK – ASSIST-CKD: identifying and monitoring people at greatest risk of progressive chronic kidney disease

BMJ – Quality improvement at scale: evaluation of the drivers and barriers to adoption and sustainability of an intervention to reduce late referral in chronic kidney disease

Kidney Research UK - Kidney disease: A UK public health emergency