The chronic kidney disease (CKD) integrated service was extended to patients living in Enfield and Haringey from Friday 19 January 2024. All patients within the north central London (NCL) catchment area will have equal access to the integrated CKD service. 

The integrated CKD service comprises:

• a consultant-led triage service 
• community-based specialist nurse/pharmacist-led CKD clinics, provided by the Royal Free London (RFL) in primary care locations  
• an education programme to support CKD management in primary care 
• prompt CKD management advice for primary care. 

Sharing the patient's EMIS record

A key aspect of the service is the consultant's direct access to the patient's EMIS record, helping to inform the clinical decision. It is important to receive explicit patient permission for the sharing of the record.  

Triage outcomes

All referrals will be triaged and a response communicated back to the referring GP within two weeks of submission. The four outcomes following triage are: 

• return to primary care with management advice 
• patient seen in nurse or pharmacist-led community clinic 
• patient referred to diagnostic/general nephrology clinic at Barnet Hospital, Royal Free Hospital, North Middlesex Hospital or Whittington Hospital 
• patient referred to specialist clinic in secondary care. 

Nurse/pharmacist-led community CKD clinic

The community CKD nursing team run autonomous nurse-led clinics, providing specialist, high-quality, expert nursing care and support for patients and their families with a diagnosis of CKD. They carry out a variety of extended or advanced nursing practices in relation to this and work with the support and governance from the lead clinician and the multi-disciplinary team. A community CKD pharmacist will soon be joining the team and will be running pharmacist-led CKD clinics. The team will have access to a specialist CKD dietitian.  

The aim of the CKD service is to delay the progression of patients' renal disease by managing risk factors and symptoms of CKD through health-related behaviour change, health education and promotion and medicines management.

For patient information leaflets, see Downloads or refer patients to the Keeping Well section of NCL ICS patient-facing website. 

Education: Virtual patient education webinars

The RFL clinical team will be running monthly 'How to look after your kidneys' webinars. These will be open to all patients with CKD and their families/carers. Details will be uploaded to the Keeping Well section of the NCL ICS website, under CKD. 

Education: Clinician education sessions

If you would like to arrange a CKD training session for your practice or PCN, email rf.communityckdservice@nhs.net 

Useful email contacts include e: rf.communityckdservice@nhs.net and e: diabetes.ckd@nhs.net (Camden only)

Eligibility Criteria

Inclusions

• Barnet, Camden, Enfield, Haringey and Islington-registered patients aged >18 with a renal disorder
• patients where a GP has concerns regarding aspects of managing CKD.

Refer to the Reasons for Referral to Nephrology section of the NCL CKD clinical pathway for guidance on referral criteria.  

Exclusions

• paediatric patients
• urgent referrals:
  • acute kidney injury (acute renal failure)
  • malignant hypertension
  • hyperkalaemia (K+ >7mmol/L)
  • nephrotic syndrome.

How to Refer

Urgent acute kidney injuries