Table 2

Elements of high-quality CKD care as defined by standard national and international CKD guidelines25 44–48

Domain	Objective	Measures
Identification of CKD risk factors	To establish an organised system for identification of people with risk factors and evaluated for the presence of CKD markers	Percentage of patients with risk factors* (present for at least 1 year) tested for CKD within the last 12 months
Identification of CKD	To establish an organised system where people with CKD are appropriately identified	Proportion of patients with CKD correctly diagnosed and appropriately coded (validated based on KDIGO definition standard of using Scr measurements to derive eGFR <60 mL/min based on two measures at least 90 days apart based on CKD-EPI equation.
Management of CKD: Monitoring of risk factors for progression and CVD	To establish an organised system to ensure patients with CKD are receiving guideline-concordant care appropriate for the stage of CKD. This implies that those with early stages are being monitored appropriately in primary care.	Proportion of patients receiving appropriate testing and monitoring: Percentage of patients with urinary albumin tested within 6 months of index GFR <60 mL/min/1.73 m² Percentage of patients with index GFR <60 mL/min/1.73 m² and diabetes mellitus who have glycated haemoglobin tested at least annually Frequency of eGFR and albuminuria testing in patients with a baseline of eGFR <60 mL/min and/or ACR of 70 mg/mmol (<1 year, 1–2 years, >2 years) Proportion of patients receiving appropriate cardiovascular risk management: Percentage of patients >50 years of age and eGFR <45 mL/min and/or CVD history on a statin medication Percentage of patients with diabetes and proteinuria on an ACEi or ARB Percentage of patients with history of CVD on appropriate secondary prevention (aspirin, beta-locker, ACEi, statin) Proportion of patients achieving treatment targets (BP, proteinuria, HbA1c). Percentage of patients with diabetes and/or proteinuria (ACR>70 mg/mmol) achieving a target BP of ≤130/80 mm Hg Percentage of patients with eGFR <60 mL/min achieving a target BP of ≤140/90 mm Hg Percentage of patients with proteinuria (ACR>70 mg/mmol) achieving a target reduction to 50% of baseline Percentage of patients with diabetes achieving a target HbA1c~7%
Appropriate referral system	To develop a system where patients with CKD that need specialist input to care are appropriately identified and referred.	Proportion of patients appropriately referred for specialist care (defined by any visit to nephrologist or multidisciplinary CKD clinic within the last 12 months, for those patients that meet the KDIGO referral criteria)†

*Diabetes, hypertension, CVD, nephrotoxic medications (non-steroidal anti-inflammatory drugs, calcineurin inhibitors, lithium), certain urological disease (eg, kidney stones, prostatic hypertrophy), multisystem diseases (eg, lupus) and family history of kidney disease.
†This would include advanced stages of CKD (eGFR<30 mL/min/1.73 m²), significant albuminuria (ACR≥70 mg/mmol), rapid loss of eGFR (>15 mL/min/1.73 m²) refractory hypertension and history of acute kidney injury.
ACEi, ACE inhibitor; ACR, albumin to creatinine ratio; ARB, angiotensin-receptor blocker; BP, blood pressure; CKD, chronic kidney disease; CVD, cardiovascular disease; eGFR, estimated glomerular filtration rate; EPI, Epidemiology Collaboration; HbA1c, glycated haemoglobin concentration; KDIGO, Kidney Disease Improving Global Outcomes; Scr, serum creatinine.