Chronic Kidney Disease Integrated Service

NCL Wide

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 and pharmacist team run autonomous clinics, providing specialist, high-quality, expert care and support for patients and their families with a diagnosis of CKD. They carry out a variety of extended or advanced clinical practices in relation to this and work with the support and governance from the lead clinician and the multi-disciplinary team. The team is supported by a specialist CKD dietitian and occupational therapist.  

The aim of the CKD service is to delay the progression of patients' kidney 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 run monthly 'How to look after your kidneys' webinars. These are open to all patients with CKD and their families/carers in NCL. 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)

Education: SGLT-2 inhibitor prescribing for clinicians

NCL ICB commissioned a programme of work from January 2025 to March 2026, to review patients with CKD stages G3a-G5 who could be prescribed an SGLT2 inhibitor, but are not, as the intervention will benefit the patient's health and self-management. SGLT-2i used appropriately in CKD can significantly affect the rates of heart attacks and strokes, and reduce the number who reach end-stage kidney disease and renal replacement therapy. To support this work, join a one-hour interactive session with experts from the NCL CKD Integrated Service. 

Event dates will be released throughout the year, until February 2026, with meeting links provided within two months of the event. Booking is by registration only, and live attendance is required for certification. Events are listed on the Events Calendar, go to the month and search 'CKD'.


Eligibility Criteria

Inclusions

  • Barnet, Camden, Enfield, Haringey and Islington-registered patients aged >18 years 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

Royal Free Hospital and Barnet Hospital

During working hours (Monday-Friday, 9am-5pm): 07908 424 284

Out of hours via switchboard.

North Middlesex University Hospital

Whittington Hospital

Out of hours via switchboard.

EMIS form

Referral methods: e-Referrals

Refer via e-RS

All CKD/Nephrology/Renal referrals in NCL should be sent via e-RS to the NCL Integrated CKD/Nephrology triage Hub - RAL. 

Complete the NCL Integrated CKD/Nephrology Triage Hub Referral Proforma and attach to your e-RS referral, if this is not attached the referral will not be visible and will not be triaged.

How to find the service on e-RS

  • Speciality: Nephrology
  • Clinic type: Nephrology
  • Service name: NCL Integrated CKD/Nephrology Triage Hub RAL 

Referrers should always include reason for referral to enable effective triage.

Referrers should also include the patient preferred/local secondary care trust if applicable.

Referrers should ensure consent to share primary record is obtained and ticked on form.

Where to find the form

  • Barnet: BAR Global Documents > Referral Forms folder 
  • Camden: Camden Global Documents > Nephrology & Urology
  • Enfield: ENF Global Documents > Nephrology & Urology 
  • Haringey: HAR Global Documents > CKD
  • Islington: ISL Global Documents > CKD  

Downloads

Download • PDF, 179.47 KB
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What is Chronic Kidney Disease (CKD)

NCL Wide
Download • PDF, 115.79 KB
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The Urine ACR Test checking kidney health

NCL Wide
Download • PDF, 137.93 KB
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Sick day medication guidance in CKD

NCL Wide
Download • PDF, 1.14 MB
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CKD infographic for GP waiting rooms

NCL Wide
Download • PDF, 179.16 KB
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CKD checklist poster for GP waiting rooms

NCL Wide
Download • PPTX, 960.35 KB
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CKD slides for GP waiting room screens

NCL Wide
Download • PDF, 1.11 MB
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How to look after your kidneys patient information leaflet

NCL Wide
Download • PDF, 1.14 MB
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How to look after your kidneys patient information leaflet (large print)

NCL Wide
Download • DOCX, 49.18 KB
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Expansion of NCL integrated CKD service (January 2024)

NCL Wide
Download • DOCX, 20.73 KB
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FAQ NCL-wide integrated chronic kidney disease service

NCL Wide

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Review date: Saturday, 21 February 2026