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Anaemia management in people with chronic kidney disease

About

What is covered

This pathway covers diagnosing and managing anaemia in children, young people and adults with chronic kidney disease. The age groups defined in this pathway are as follows:
  • children: 13 years and under
  • young people: 14 to 17 years
  • adults: 18 years and over.

Updates

Updates to this pathway

2 June 2015 Update on publication of anaemia management in chronic kidney disease (NICE guideline NG8).

Professional responsibilities

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Short Text

Everything NICE has said on managing anaemia in people with chronic kidney disease in an interactive flowchart

What is covered

This pathway covers diagnosing and managing anaemia in children, young people and adults with chronic kidney disease. The age groups defined in this pathway are as follows:
  • children: 13 years and under
  • young people: 14 to 17 years
  • adults: 18 years and over.

Updates

Updates to this pathway

2 June 2015 Update on publication of anaemia management in chronic kidney disease (NICE guideline NG8).

Sources

NICE guidance and other sources used to create this pathway.
Chronic kidney disease in adults (2011 updated 2014) NICE quality standard 5

Quality standards

Chronic kidney disease in adults quality standard

These quality statements are taken from the chronic kidney disease in adults quality standard. The quality standard defines clinical best practice in chronic kidney disease care and should be read in full.

Quality statements

Specialist referral

This quality statement is taken from the chronic kidney disease quality standard. The quality standard defines clinical best practice in chronic kidney disease (CKD) care and should be read in full.

Quality statement

People with CKD who may benefit from specialist care are referred for specialist assessment in accordance with NICE guidance.

Quality measure

Structure
Evidence of local arrangements to ensure that people with CKD who may benefit from specialist care are referred for specialist assessment in accordance with NICE guidance.
Process
Proportion of people with CKD in defined at-risk groups who are referred for specialist assessment.
Numerator – the number of people in the denominator referred for specialist assessment.
Denominator – the number of people with CKD in defined at-risk groups.
An audit standard of less than 100% should be expected for this process measure, to allow for cases where the practitioner considers it is not in the best interests of the person concerned to be referred.

What the quality statement means for each audience

Service providers ensure that systems are in place to refer people with CKD who may benefit from specialist care, for specialist assessment, in accordance with NICE guidance.
Healthcare professionals ensure they refer people with CKD who may benefit from specialist care for specialist assessment in accordance with NICE guidance.
Commissioners ensure they commission services that refer people with CKD who may benefit from specialist care for specialist assessment in accordance with NICE guidance.
People with CKD who may benefit from specialist care are referred for specialist assessment (see patient information for further details).

Source guidance

Data source

Structure
Local data collection.
Process
Local data collection.
The UK Renal Registry collects data from renal services on referral source and date.

Definitions

Chronic kidney disease (NICE guideline CG182) recommends that people with CKD in the following groups should normally be referred for specialist assessment:
  • GFR less than 30 ml/min/1.73 m2 (GFR category G4 or G5), with or without diabetes
  • ACR 70 mg/mmol or more, unless known to be caused by diabetes and already appropriately treated
  • ACR 30 mg/mmol or more (ACR category A3), together with haematuria
  • sustained decrease in GFR of 25% or more, and a change in GFR category or sustained decrease in GFR of 15 ml/min/1.73 m2 or more within 12 months
  • hypertension that remains poorly controlled despite the use of at least 4 antihypertensive drugs at therapeutic doses (see also Hypertension [NICE guideline CG127])
  • known or suspected rare or genetic causes of CKD
  • suspected renal artery stenosis.

Cardiovascular risk

This quality statement is taken from the chronic kidney disease quality standard. The quality standard defines clinical best practice in chronic kidney disease (CKD) care and should be read in full.

Quality statement

People with CKD are assessed for cardiovascular risk.

Quality measure

Structure
Evidence of local arrangements to ensure that people with CKD are assessed for cardiovascular risk.
Process
Proportion of people with CKD who are assessed for cardiovascular risk.
Numerator – the number of people in the denominator assessed for cardiovascular risk.
Denominator – the number of people with CKD.

What the quality statement means for each audience

Service providers ensure that people with CKD are assessed for cardiovascular risk.
Healthcare professionals ensure they assess people with CKD for cardiovascular risk.
Commissioners ensure they commission services that assess people with CKD for cardiovascular risk.
People with CKD are assessed for their risk of heart problems.

Source guidance

Data source

Structure
Local data collection.
Process
Local data collection.

Definitions

The Renal Association clinical practice guideline: cardiovascular disease in CKD suggests recording the following as part of a cardiovascular risk assessment:
  • angina and myocardial infarction
  • previous coronary angioplasty or coronary artery bypass grafting
  • stroke and transient ischaemic attack
  • previous carotid artery surgery or angioplasty
  • peripheral vascular disease or previous intervention
  • cardiac failure
  • arrhythmias (supraventricular and ventricular)
  • diabetes
  • ethnicity.
Healthy lifestyle factors including smoking, weight control and exercise should also be discussed.

Equality and diversity considerations

Cardiovascular risk is higher in some black and minority ethnic groups and this should be considered as part of an overall assessment of risk for cardiovascular disease.

Anaemia treatment

This quality statement is taken from the chronic kidney disease quality standard. The quality standard defines clinical best practice in chronic kidney disease (CKD) care and should be read in full.

Quality statement

People with anaemia of CKD have access to and receive anaemia treatment in accordance with NICE guidance.

Quality measure

Structure
a) Evidence of local arrangements to ensure that people with anaemia of CKD have access to and receive anaemia treatment in accordance with NICE guidance.
b) Evidence of local agreed protocols defining roles and responsibilities of healthcare professionals in primary and secondary care for managing the treatment of people with anaemia of CKD.
Process
a) Proportion of people with anaemia of CKD with recorded haemoglobin less than or equal to 10 g/dl who are either receiving anaemia treatment or for whom there is a valid reason for it not being offered or taken up.
Numerator – the number of people in the denominator either receiving anaemia treatment or for whom there is a valid reason for it not being offered or taken up.
Denominator – the number of people with anaemia of CKD with recorded haemoglobin less than or equal to 10 g/dl.
Outcome
Proportion of people with anaemia of CKD receiving maintenance anaemia treatment who have haemoglobin levels within the typical aspirational range 10–12 g/dl.
Numerator – the number of people in the denominator with haemoglobin levels within the typical aspirational range 10–12 g/dl.
Denominator – the number of people with anaemia of CKD receiving maintenance anaemia treatment.
An audit standard of less than 100% is expected for this outcome to allow for patient preferences, other symptoms and comorbidities, underlying causes for poor response and patients who are in the induction phase of their treatment.

What the quality statement means for each audience

Service providers ensure that systems are in place to provide people with anaemia of CKD access to anaemia treatment in accordance with NICE guidance.
Healthcare professionals assess whether people with anaemia of CKD are likely to benefit from anaemia treatment in terms of quality of life, physical function or avoidance of blood transfusion and if so, offer people with anaemia of CKD treatment for their anaemia in accordance with NICE guidance.
Commissioners ensure they commission services that can provide people with anaemia of CKD access to anaemia treatment in accordance with NICE guidance.
People with anaemia of CKD (which is low levels of red blood cells due to CKD) are assessed to find out whether they are likely to benefit from anaemia treatment and, if suitable, receive anaemia treatment.

Source guidance

  • Recommendations on the management of anaemia and assessment and optimisation of erythropoiesis are contained within sections 1.2 and 1.3 of NICE clinical guideline 114 (includes key priorities for implementation 1.3.1.1, 1.3.5.1, 1.3.8.1, 1.3.8.2, 1.3.8.5 and 1.3.12.1).

Data source

Structure
Local data collection. Contained within NICE clinical guideline 114 audit criteria.
Process
Local data collection.
Outcome
Local data collection for patients not on dialysis. The UK Renal Registry collects data on pre-dialysis and post-dialysis haemoglobin levels from patients in renal units and the prescription of iron and erythropoietin stimulating agents (ESAs). Contained within NICE clinical guideline 114 audit criteria, criterion 4.

Definitions

Anaemia treatment includes iron supplementation and ESAs.
NICE clinical guideline 114 recommends that treatment with ESAs is offered to people with anaemia of CKD who are likely to benefit in terms of quality of life and physical function and that age alone should not be a determinant for the treatment of anaemia of CKD. When determining individual aspirational haemoglobin ranges for people with anaemia of CKD, patient preferences, symptoms and comorbidities and the required treatment should all be taken into account.
To ensure that ESA treatment is clinically effective, consistent and safe, a patient-centred plan should be agreed between the prescriber and patient to include:
  • continuity of drug supply
  • flexibility of where the drug is delivered and administered
  • lifestyle and preferences of the patient
  • cost of drug supply
  • desire for self-care where appropriate
  • regular review of the plan in light of changing needs.

Equality and diversity considerations

This statement promotes equality by ensuring that all people, including people with comorbidities, which may include a significant number of older people, are not excluded from (a trial of) anaemia treatment if they are likely to benefit.

Preparing for renal replacement therapy

This quality statement is taken from the chronic kidney disease quality standard. The quality standard defines clinical best practice in chronic kidney disease (CKD) care and should be read in full.

Quality statement

People with progressive CKD whose eGFR is less than 20 ml/min/1.73 m2, and/or who are likely to progress to established kidney failure within 12 months, receive unbiased personalised information on established kidney failure and renal replacement therapy options.

Quality measure

Structure
a) Evidence of local arrangements to ensure that people with progressive CKD whose estimated glomerular filtration rate (eGFR) is less than 20 ml/min/1.73 m2, and/or who are likely to progress to established kidney failure within 12 months, receive unbiased personalised information on established kidney failure and renal replacement therapy options.
b) Evidence of local procedures to document the outcome of discussions with people with CKD about renal replacement therapy options, with reasons for the uptake of a particular modality.
c) Evidence of local arrangements to collect, analyse and act upon patient feedback on whether they felt that informed choice was available to them.
d) Evidence of local arrangements for provision and distribution of written materials on established kidney failure and renal replacement therapy options.
Process
a) Proportion of people with progressive CKD whose eGFR is less than 20 ml/min/1.73 m2, and/or who are likely to progress to established kidney failure within 12 months, known to renal services with progressive CKD for 3 months or more, who receive unbiased personalised information regarding established kidney failure and renal replacement therapy options.
Numerator – the number of people in the denominator receiving unbiased personalised information regarding established kidney failure and renal replacement therapy options.
Denominator – the number of people with progressive CKD whose eGFR is less than 20 ml/min/1.73 m2, and/or who are likely to progress to established kidney failure within 12 months, known to renal services with progressive CKD for 3 months or more.
b) Proportion of people on long-term dialysis who started dialysis in an unplanned way who receive unbiased personalised information regarding established kidney failure and renal replacement therapy options at the earliest opportunity.
Numerator – the number of people in the denominator receiving unbiased personalised information regarding established kidney failure and renal replacement therapy options at the earliest opportunity following dialysis start.
Denominator – the number of people on long-term dialysis who started dialysis in an unplanned way.
Outcomes
a) Proportion of people who start long-term renal replacement therapy via the modality which they initially selected.
Numerator – the number of people in the denominator receiving renal replacement therapy via the modality which they initially selected.
Denominator – the number of people starting long-term dialysis.
b) Proportion of people on long-term dialysis who are on peritoneal dialysis.
Numerator – the number of people in the denominator on peritoneal dialysis.
Denominator – the number of people on long-term dialysis.
c) Proportion of people on long-term dialysis who are on home haemodialysis.
Numerator – the number of people in the denominator on home haemodialysis.
Denominator – the number of people on long-term dialysis.
Transplantation uptake is addressed in the NICE quality standard for renal replacement therapy services, see quality statement 2: Transplantation – pre-emptive and quality statement 3: Transplantation – on dialysis.

What the quality statement means for each audience

Service providers ensure they provide people with progressive CKD whose eGFR is less than 20 ml/min/1.73 m2, and/or who are likely to progress to established kidney failure within 12 months, with unbiased personalised information on established kidney failure and renal replacement therapy options.
Healthcare professionals provide unbiased personalised information on established kidney failure and renal replacement therapy options to people with progressive CKD whose eGFR is less than 20 ml/min/1.73 m2, and/or who are likely to progress to established kidney failure within 12 months.
Commissioners ensure they commission services that provide unbiased personalised information on established kidney failure and renal replacement therapy options to people with progressive CKD whose eGFR is less than 20 ml/min/1.73 m2, and/or who are likely to progress to established kidney failure within 12 months.
People with advanced CKD that is getting worse and/or whose kidneys are likely to fail within 12 months receive information specific to their situation about their condition and possible treatment options.

Source guidance

Data source

Structure
Local data collection.
Process
Outcome
Local data collection. Hospital Episode Statistics (HES) contains data on compensation for renal failure. The Office of population censuses and survey classification of surgical operations and procedures (OPCS-4) code for this is X40, with subcategories 0–9. The UK Renal Registry collects data on renal treatment modality.

Definitions

People with progressive CKD whose eGFR is less than 20 ml/min/1.73 m2, and/or who are likely to progress to established kidney failure within 12 months, includes people who start dialysis in an unplanned way and people with failing kidney transplants. All people in these groups should have access to unbiased personalised information on established renal failure and renal replacement therapy options.
Information should, as part of a care plan, include:
  • transplantation
  • home haemodialysis
  • peritoneal dialysis
  • haemodialysis
  • conservative management.
It should also enable patients to make an informed decision about their treatment. A care plan is defined in quality statement 3 – Planning care.

Equality and diversity considerations

All information about treatment and care should be culturally appropriate. It should also be accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English. People with CKD should have access to an interpreter or advocate if needed.

Psychosocial support

This quality statement is taken from the chronic kidney disease quality standard. The quality standard defines clinical best practice in chronic kidney disease (CKD) care and should be read in full.

Quality statement

People with established renal failure have access to psychosocial support (which may include support with personal, family, financial, employment and/or social needs) appropriate to their circumstances.

Quality measure

Structure
Evidence of local arrangements to ensure that people with established renal failure have access to psychosocial support (which may include support with personal, family, financial, employment and/or social needs) appropriate to their circumstances.
Process
Proportion of people with established renal failure who receive psychosocial support (which may include support with personal, family, financial, employment and/or social needs) appropriate to their circumstances.
Numerator – the number of people in the denominator receiving psychosocial support (which may include support with personal, family, financial, employment and/or social needs) appropriate to their circumstances.
Denominator – the number of people with established renal failure.

What the quality statement means for each audience

Service providers ensure that systems are in place to provide people with established renal failure access to psychosocial support (including support with personal, family, financial, employment and/or social needs) appropriate to their circumstances.
Health and social care professionals provide people with established renal failure with access to psychosocial support (which may include support with personal, family, financial, employment and/or social needs) appropriate to their circumstances.
Commissioners ensure they commission services that provide people with established renal failure access to psychosocial support (which may include support with personal, family, financial, employment and/or social needs) appropriate to their circumstances.
People with established renal failure can obtain help and support with personal, family, financial, employment and social problems related to their condition.

Source guidance

Data source

Structure
Local data collection.
Process
Local data collection.

Definitions

Renal services should inform people with CKD about external support services and groups where available, as well as providing psychosocial support within the renal service itself. This may or may not include access to a dedicated counsellor.

Acute illness

This quality statement is taken from the chronic kidney disease quality standard. The quality standard defines clinical best practice in chronic kidney disease (CKD) care and should be read in full.

Quality statement

People with CKD who become acutely unwell have their medication reviewed, and receive an assessment of volume status and renal function.

Quality measure

Structure
Evidence of local arrangements to ensure that people with CKD who become acutely unwell have their medication reviewed, and receive an assessment of volume status and renal function.
Process
Proportion of people with CKD presenting acutely unwell who have their medication reviewed, and receive an assessment of volume status and renal function.
Numerator – the number of people in the denominator having their medication reviewed and receiving an assessment of volume status and renal function.
Denominator – the number of people with CKD presenting acutely unwell.

What the quality statement means for each audience

Service providers ensure that a medication review and assessment of volume status and renal function is carried out in people with CKD who become acutely unwell.
Healthcare professionals review medication, and perform assessments of volume status and renal function for people with CKD who become acutely unwell.
Commissioners ensure they commission services that review medication, and perform assessments of volume status and renal function for people with CKD who become acutely unwell.
People with CKD who suddenly become unwell have their medication checked and are assessed to find out how well their kidneys are working.

Source guidance

Data source

Structure
Local data collection.
Process
Local data collection.

Definitions

An acute illness is a disease with an abrupt onset and short course. In this context ‘acutely unwell' is defined as an episode where the health of the person with CKD gets worse suddenly. This may or may not be related to CKD and applies to presentation in all healthcare settings, including both primary and secondary care.

Identification

This quality statement is taken from the chronic kidney disease quality standard. The quality standard defines clinical best practice in chronic kidney disease (CKD) care and should be read in full.

Quality statement

People with risk factors for CKD are offered testing, and people with CKD are correctly identified.

Quality measure

Structure
Evidence of local arrangements to ensure that people with risk factors for CKD are identified and offered testing and that all people receiving testing for CKD are tested and diagnosed in accordance with NICE guidance.
Process
a) Proportion of people with risk factors for CKD who receive testing.
Numerator – the number of people in the denominator receiving testing for CKD.
Denominator – the number of people with risk factors for CKD.
b) Proportion of people who are tested for CKD and diagnosed in accordance with NICE guidance.
Numerator – the number of people in the denominator tested and diagnosed in accordance with NICE guidance.
Denominator – the number of people tested for CKD.
Outcome
Increase in the total number of people correctly diagnosed with CKD.
Consideration should be given to comparing the number of people diagnosed with CKD with estimated prevalence figures.

What the quality statement means for each audience

Service providers ensure that systems are in place to offer testing to people with risk factors for CKD, and that all testing and diagnosis is carried out in accordance with NICE guidance.
Healthcare professionals ensure they offer testing to people with risk factors for CKD and carry out all testing and diagnosis in accordance with NICE guidance.
Commissioners ensure they commission services that offer testing to people with risk factors for CKD, and that all testing and diagnosis is carried out in accordance with NICE guidance.
People who are at particular risk of CKD are offered tests for CKD (see patient information for further details).
People with CKD are tested and correctly diagnosed with the condition.

Source guidance

  • Recommendations on investigation of CKD are contained within section 1.1 and recommendation 1.2.2 of chronic kidney disease (NICE guideline CG182).

Data source

Structure
Local data collection.
Process
a) Local data collection.
Quality and Outcomes Framework (QOF) indicator DM 13: the percentage of patients with diabetes who have a record of microalbuminuria testing in the previous 15 months (exception reporting for patients with proteinuria).
QOF indicator DM 22: the percentage of patients with diabetes who have a record of estimated glomerular filtration rate (eGFR) or serum creatinine testing in the previous 15 months.
QOF indicator MH 4: the percentage of patients on lithium therapy with a record of serum creatinine and thyroid stimulating hormone in the preceding 15 months.
The National Diabetes Audit also collects data on albuminuria and creatinine testing in people with diabetes.
b) Local data collection.
Outcome
Local data collection for stages 1 and 2.
QOF indicator CKD 1: the practice can produce a register of patients aged 18 years and over with CKD (US National Kidney Foundation: Stage 3 to 5 CKD).

Definitions

Chronic kidney disease (NICE guideline CG182) states that testing for CKD using eGFRcreatinine and albumin:creatinine ratio (ACR) should be offered to people with any of the following risk factors:
  • diabetes
  • hypertension
  • acute kidney injury
  • cardiovascular disease (ischaemic heart disease, chronic heart failure, peripheral vascular disease and cerebral vascular disease)
  • structural renal tract disease, recurrent renal calculi or prostatic hypertrophy
  • multisystem diseases with potential kidney involvement, for example, systemic lupus erythematosus
  • family history of end‑stage kidney disease (GFR category G5) or hereditary kidney disease
  • opportunistic detection of haematuria.
The new section 1.1 in chronic kidney disease (NICE guideline CG182) contains additional recommendations to provide clarification on measurement of kidney function using GFR and how to ensure values are correctly interpreted. Also amended recommendations on tests to detect and identify proteinuria and who should be tested for CKD are within this section.

Equality and diversity considerations

An ethnicity correction factor is required for reporting GFR values for people of African-Caribbean ethnicity to ensure correct diagnosis and assessment.
Correct identification and assessment of older people requires added caution. Although CKD prevalence is higher in older populations, an eGFR in the range 45–59 ml/min/1.73 m2, if stable over time and without any other evidence of kidney damage, in people aged over 70 years, should be considered unlikely to be associated with CKD-related complications.
This statement may not address under-identification in groups who are under-represented on primary care registers, such as homeless people and people who rarely visit their GP.

Planning care

This quality statement is taken from the chronic kidney disease quality standard. The quality standard defines clinical best practice in chronic kidney disease (CKD) care and should be read in full.

Quality statement

People with CKD have a current agreed care plan appropriate to the stage and rate of progression of CKD.

Quality measure

Structure
a) Evidence of local arrangements to ensure that people with CKD have a current agreed care plan appropriate to the stage and rate of progression of CKD (verbal or written), including an advance care plan for end of life care where appropriate.
b) Evidence of local arrangements to ensure that renal units that are able to use PatientView promote access to it using verbal and written information.
c) Evidence of local arrangements to collect, analyse and act upon patient questionnaires of how informed patients are and how informed they feel following renal-related appointments.
Process
a) Proportion of people with CKD who have a current agreed care plan appropriate to the stage and rate of progression of CKD.
Numerator – the number of people in the denominator with a current agreed care plan appropriate to the stage and rate of progression of CKD.
Denominator – the number of people with CKD.
b) Proportion of people with CKD needing end of life care including those receiving conservative management of established kidney failure, who have a jointly agreed advance care plan.
Numerator – the number of people in the denominator with a jointly agreed advance care plan.
Denominator – the number of people with CKD needing end of life care including those receiving conservative management of established kidney failure.

What the quality statement means for each audience

Service providers ensure that systems are in place to develop current agreed care plans with people who have CKD appropriate to the stage and rate of progression of CKD, including an advance care plan for end of life care if appropriate.
Health and social care professionals develop and maintain current agreed care plans with people who have CKD that is appropriate to the stage and rate of progression of CKD, including an advance care plan for end of life care if appropriate.
Commissioners ensure they commission services that develop and maintain current agreed care plans with people who have CKD appropriate to the stage and rate of progression of CKD, including an advance care plan for end of life care if appropriate.
People with CKD receive information suitable for how advanced their condition is, which explains their condition and the care they will receive, and are involved in decisions about their current and future care.

Source guidance

Data source

Structure
Local data collection.
Process

Definitions

A care plan incorporates the provision of information on diagnosis and prognosis, multidisciplinary support, education for self care and how future care will be provided. It places emphasis on person-centred care and shared decision-making. A care plan is a process and may take a written, verbal or electronic form to include the following.
All stages:
  • People should feel informed about what CKD is and how it affects them, what they need to do and why it is important for them to do this.
  • Treatments available for CKD, and their advantages and disadvantages.
  • Complications or side effects that may occur as a result of treatment or medication.
  • What people can do to manage and influence their own condition.
  • Information about the ways in which CKD and the treatment may affect people's daily life, social activities, work opportunities and financial situation, including benefits and allowances available.
  • Information about how to cope with and adjust to CKD and sources of psychological support.
  • Drugs that should be used with caution or at reduced dose in people with CKD.
Stages 4–5:
  • Risks and benefits of renal replacement therapy options to ensure informed choice.
  • Information about kidney transplantation, including pre-emptive transplantation.
  • Importance of timely access placement for dialysis.
  • End of life care, including a jointly agreed advance care plan.
People receiving conservative management of kidney disease:
  • Supportive medical care (excluding dialysis and transplantation).
  • Specialist palliative care.
A care plan is current and agreed when it relates to the most recent care delivered as well as forthcoming care that is planned, and when it reflects ongoing shared decision-making between healthcare professionals and the person with CKD.
PatientView enables people with CKD to access online information about their diagnosis, treatment, and latest test results. PatientView is only available from some UK renal units, and for patients who have chosen to participate.
NICE has produced information about NICE guidance, written specifically for patients, on chronic kidney disease and treating anaemia in people with chronic kidney disease.
A guide to implementing kidney care plans is available from NHS Kidney Care.

Equality and diversity considerations

All information about treatment and care should be culturally appropriate. It should also be accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English. People with CKD should have access to an interpreter or advocate if needed.
Uptake of PatientView is dependent on IT access and computer literacy and is only available in English. Some groups, particularly low-income households and people whose first language is not English may not be able to access PatientView. Additionally, PatientView is only available in some renal units. People unable to or choosing not to access PatientView should receive the same information from their renal unit via different means, such as a verbal discussion with a healthcare professional.

Blood pressure control

This quality statement is taken from the chronic kidney disease quality standard. The quality standard defines clinical best practice in chronic kidney disease (CKD) care and should be read in full.

Quality statement

People with higher levels of proteinuria, and people with diabetes and microalbuminuria, are enabled to safely maintain their systolic blood pressure within a target range 120–129 mmHg and their diastolic blood pressure below 80 mmHg.

Quality measure

Structure
Evidence of local arrangements to ensure that people with higher levels of proteinuria, and people with diabetes and microalbuminuria, are enabled to safely maintain their systolic blood pressure within a target range 120–129 mmHg and their diastolic blood pressure below 80 mmHg.
Process
a) Proportion of people with higher levels of proteinuria with a recording of blood pressure in the previous 9 months.
Numerator – the number of people in the denominator with a recording of blood pressure in the previous 9 months.
Denominator – the number of people with higher levels of proteinuria.
b) Proportion of people with diabetes and microalbuminuria with a recording of blood pressure in the previous 9 months.
Numerator – the number of people in the denominator with a recording of blood pressure in the previous 9 months.
Denominator – the number of people with diabetes and microalbuminuria.
Outcome
a) Proportion of people with higher levels of proteinuria with a recording of blood pressure in the previous 9 months, whose latest systolic blood pressure reading is in the range 120–129 mmHg and diastolic blood pressure below 80 mmHg.
Numerator – the number of people in the denominator with latest systolic blood pressure in the range 120–129 mmHg and diastolic blood pressure below 80 mmHg.
Denominator – the number of people with higher levels of proteinuria with a recording of blood pressure in the previous 9 months.
An audit standard of less than 100% is expected for outcome a) to account for measurement variability, intercurrent illness and to avoid any risks associated with overtreatment.
b) Proportion of people with diabetes and microalbuminuria with a recording of blood pressure in the previous 9 months, whose latest systolic blood pressure reading is in the range 120–129 mmHg and diastolic blood pressure below 80 mmHg.
Numerator – the number of people in the denominator with latest systolic blood pressure in the range 120–129 mmHg and diastolic blood pressure below 80 mmHg.
Denominator – the number of people with diabetes and microalbuminuria with a recording of blood pressure in the previous 9 months.
An audit standard of less than 100% is expected for outcome b) to account for measurement variability, intercurrent illness and to avoid any risks associated with overtreatment.

What the quality statement means for each audience

Service providers ensure that systems are in place to enable people with higher levels of proteinuria and people with diabetes and microalbuminuria to safely control their systolic blood pressure, typically within the target range 120–129 mmHg and their diastolic blood pressure below 80 mmHg.
Healthcare professionals ensure they enable people with higher levels of proteinuria and people with diabetes and microalbuminuria to safely control their systolic blood pressure, typically within the target range 120–129 mmHg and their diastolic blood pressure below 80 mmHg.
Commissioners ensure they commission services that enable people with higher levels of proteinuria and people with diabetes and microalbuminuria to safely control their systolic blood pressure, typically within the target range 120–129 mmHg and their diastolic blood pressure below 80 mmHg.
People with large amounts of protein in their urine are given support to help control their blood pressure.
People with diabetes and protein in their urine are given support to help control their blood pressure.

Source guidance

Data source

Structure
Local data collection.
Process
Local data collection.
Outcome
Local data collection.

Definitions

Chronic kidney disease (NICE guideline CG182) recommends that in people with CKD and diabetes, and also in people with an ACR of 70 mg/mmol or more, aim to keep the systolic blood pressure below 130 mmHg (target range 120–129 mmHg) and the diastolic blood pressure below 80 mmHg.
All blood pressure targets should be based on clinical judgment and tailored to the individual taking into consideration other health conditions, medications and age.

Equality and diversity considerations

While not essential, self-monitoring of blood pressure can play a helpful role in blood pressure control. The precise equipment required for this can be quite expensive, which can disadvantage people in lower socioeconomic groups.
The relationship between creatinine generation and muscle mass means that ACRs, when used to characterise microalbuminuria, are interpreted slightly differently in men and women.

Progression

This quality statement is taken from the chronic kidney disease quality standard. The quality standard defines clinical best practice in chronic kidney disease (CKD) care and should be read in full.

Quality statement

People with CKD are assessed for disease progression.

Quality measure

Structure
Evidence of local arrangements to ensure that people with CKD are assessed for disease progression.
Process
Proportion of people with CKD who are assessed for disease progression in accordance with current NICE guidance.
Numerator – the number of people in the denominator assessed for disease progression in accordance with current NICE guidance.
Denominator – the number of people with CKD.

What the quality statement means for each audience

Service providers ensure that systems are in place to assess people with CKD for disease progression.
Healthcare professionals ensure they assess people with CKD for disease progression.
Commissioners ensure they commission services that assess people with CKD for disease progression.
People with CKD are assessed to find out whether the disease is getting worse.

Source guidance

Data source

Structure
Local data collection.
Process
Local data collection. Quality and Outcomes Framework (QOF) indicator CKD 6: the percentage of patients on the CKD register whose notes have a record of an albumin:creatinine ratio (ACR) (or protein:creatinine ratio [PCR]) test in the previous 15 months.

Definitions

Chronic kidney disease (NICE guideline CG182) recommends the following steps to identify the rate of progression of CKD:
  • Obtain a minimum of 3 GFR estimations over a period of not less than 90 days.
  • In people with a new finding of reduced GFR, repeat the GFR within 2 weeks to exclude causes of acute deterioration of GFR – for example, acute kidney injury or starting renin–angiotensin system antagonist therapy. [recommendation 1.3.4]
Chronic kidney disease (NICE guideline CG182) recommends awareness that people with CKD are at increased risk of progression to end stage kidney disease if they have either of the following:
  • a sustained decrease in GFR of 25% or more over 12 months or
  • a sustained decrease in GFR of 15 ml/min/1.73 m2 or more over 12 months. [recommendation 1.3.5]
Chronic kidney disease (NICE guideline CG182) recommends that when assessing CKD progression, extrapolate the current rate of decline of GFR and take this into account when planning intervention strategies, particularly if it suggests that the person might need renal replacement therapy in their lifetime. [recommendation 1.3.6]

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Effective interventions library

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Implementation

NICE has produced resources to help implement its guidance on:

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Pathway information

Professional responsibilities

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Supporting information

People with anaemia of CKD should not have iron levels checked earlier than 1 week after receiving intravenous iron. The length of time to monitoring of iron status is dependent on the product used and the amount of iron given.
Routine monitoring of iron stores to prevent iron overload using serum ferritin should be at intervals of 1–3 months.

Diagnostic tests to determine iron status and predict response to iron therapy

Anaemia management in people with chronic kidney disease NG8 contains new recommendations on diagnostic tests (see diagnosis in this pathway). The anticipated national savings of using the newly recommended tests are discussed in the costing statement. The increased use of percentage of hypochromic red blood cells (HRC) tests is likely to lead to more accurate diagnosis, as a result of the considerably higher sensitivity and specificity of HRC testing. The table below indicates test accuracy and estimated cost. This may be useful for clinicians in primary and secondary care responsible for requesting the recommended tests. It could also help to support a change to electronic pathology ordering systems and provide a rationale for purchasing new lab analysers. For further details, please see full guideline section 4.3.
Test strategy
Sensitivity
Specificity
Estimated laboratory charge per test (£)
Use percentage of hypochromic red blood cells (% HRC; more than 6% only if processing of blood sample is possible within 6 hours)
82%
95%
3.04
If using percentage of hypochromic red blood cells is not possible, use reticulocyte haemoglobin content (less than 29 pg) or equivalent tests, for example, reticulocyte haemoglobin equivalent.
57%
93%
4.71
If the above tests are not available or the person has thalassaemia or thalassaemia trait, use a combination of transferrin saturation (less than 20%) and serum ferritin measurement (less than 100 micrograms/litre).
Transferrin saturation
64%
6.18
Serum ferritin (SF) 39%
81%
5.11
Do not request transferrin saturation or serum ferritin measurement alone to assess iron deficiency status in people with anaemia of CKD.

Glossary

angiotensin-converting enzyme
chronic kidney disease
erythropoiesis-stimulating agent
erythropoiesis-stimulating agents
estimated glomerular filtration rate
General Medical Council's
haemoglobin
maximum of 2 infusions – for adults a minimum of 500 mg of iron in each infusion
percentage hypochromic red cells
more than 2 infusions – for adults typically a dose of between 100 to 200 mg of iron in each infusion
Medicines and Healthcare products Regulatory Agency
includes people with a failing transplant and people having conservative management
pure red cell aplasia
Healthcare delivered outside hospitals. It includes a range of services provided by GPs, nurses, health visitors, midwives and other healthcare professionals and allied health professionals such as dentists, pharmacists and opticians. It includes community clinics, health centres and walk-in centres.
Healthcare provided in hospitals. It includes accident and emergency departments, outpatient departments, antenatal services, genitourinary medicine and sexual health clinics.

Paths in this pathway

Pathway created: May 2011 Last updated: November 2016

© NICE 2016

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