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Chronic kidney disease overview

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Chronic kidney disease HAI

About

What is covered

This pathway covers the early identification and management of chronic kidney disease in adults in primary and secondary care.
CKD describes abnormal kidney function and/or structure. It is common, frequently unrecognised and often exists together with other conditions (such as cardiovascular disease and diabetes). Moderate to severe CKD is also associated with an increased risk of other significant adverse outcomes such as acute kidney injury, falls, frailty and mortality. The risk of developing CKD increases with age. As kidney dysfunction progresses, some coexisting conditions become more common and increase in severity. CKD can progress to end-stage kidney disease in a small but significant percentage of people.
CKD is usually asymptomatic, but it is detectable, and tests for CKD are simple and freely available. There is evidence that treatment can prevent or delay the progression of CKD, reduce or prevent the development of complications, and reduce the risk of cardiovascular disease. However, CKD is often unrecognised because there are no specific symptoms, and it is often not diagnosed or diagnosed at an advanced stage.
The pathway will assume that prescribers will use a drug's summary of product characteristics to inform decisions made with individual patients.
Detailed advice on the management of CKD–mineral and bone disorders, and metabolic acidosis is beyond the scope of this pathway. If uncertain, seek advice from your local renal service.

Classification of CKD

CKD is classified according to eGFR and ACR (see chronic kidney disease classification table), using 'G' to denote the GFR category (G1–G5, which have the same GFR thresholds as the CKD stages 1–5 recommended previously) and 'A' for the ACR category (A1–A3), for example:
  • A person with an eGFR of 25 ml/min/1.73 m2 and an ACR of 15 mg/mmol has CKD G4A2.
  • A person with an eGFR of 50 ml/min/1.73 m2 and an ACR of 35 mg/mmol has CKD G3aA3.
  • An eGFR of less than 15 ml/min/1.73 m2 (GFR category G5) is referred to as kidney failure.

Updates

Updates to this pathway

23 September 2014 Link added to lithium monitoring recommendations in the bipolar disorder pathway.
22 July 2014 The new guideline on chronic kidney disease replaces the original guideline so this pathway has been redrawn.
10 September 2013 Minor maintenance updates
27 August 2013 Link to acute kidney injury pathway added.
12 March 2013 Link to hyperphosphataemia in chronic kidney disease pathway added and minor maintenance updates.
18 January 2013 Minor maintenance updates.
7 August 2012 Minor maintenance updates.
4 May 2012 Minor maintenance updates.
25 October 2011 Peritoneal dialysis path added.

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Short Text

Chronic kidney disease: early identification and management of chronic kidney disease in adults in primary and secondary care

What is covered

This pathway covers the early identification and management of chronic kidney disease in adults in primary and secondary care.
CKD describes abnormal kidney function and/or structure. It is common, frequently unrecognised and often exists together with other conditions (such as cardiovascular disease and diabetes). Moderate to severe CKD is also associated with an increased risk of other significant adverse outcomes such as acute kidney injury, falls, frailty and mortality. The risk of developing CKD increases with age. As kidney dysfunction progresses, some coexisting conditions become more common and increase in severity. CKD can progress to end-stage kidney disease in a small but significant percentage of people.
CKD is usually asymptomatic, but it is detectable, and tests for CKD are simple and freely available. There is evidence that treatment can prevent or delay the progression of CKD, reduce or prevent the development of complications, and reduce the risk of cardiovascular disease. However, CKD is often unrecognised because there are no specific symptoms, and it is often not diagnosed or diagnosed at an advanced stage.
The pathway will assume that prescribers will use a drug's summary of product characteristics to inform decisions made with individual patients.
Detailed advice on the management of CKD–mineral and bone disorders, and metabolic acidosis is beyond the scope of this pathway. If uncertain, seek advice from your local renal service.

Classification of CKD

CKD is classified according to eGFR and ACR (see chronic kidney disease classification table), using 'G' to denote the GFR category (G1–G5, which have the same GFR thresholds as the CKD stages 1–5 recommended previously) and 'A' for the ACR category (A1–A3), for example:
  • A person with an eGFR of 25 ml/min/1.73 m2 and an ACR of 15 mg/mmol has CKD G4A2.
  • A person with an eGFR of 50 ml/min/1.73 m2 and an ACR of 35 mg/mmol has CKD G3aA3.
  • An eGFR of less than 15 ml/min/1.73 m2 (GFR category G5) is referred to as kidney failure.

Updates

Updates to this pathway

23 September 2014 Link added to lithium monitoring recommendations in the bipolar disorder pathway.
22 July 2014 The new guideline on chronic kidney disease replaces the original guideline so this pathway has been redrawn.
10 September 2013 Minor maintenance updates
27 August 2013 Link to acute kidney injury pathway added.
12 March 2013 Link to hyperphosphataemia in chronic kidney disease pathway added and minor maintenance updates.
18 January 2013 Minor maintenance updates.
7 August 2012 Minor maintenance updates.
4 May 2012 Minor maintenance updates.
25 October 2011 Peritoneal dialysis path added.

Sources

NICE guidance

The NICE guidance that was used to create the pathway.
Chronic kidney disease. NICE clinical guideline 182 (2014)
Peritoneal dialysis. NICE clinical guideline 125 (2011)
Immunosuppressive therapy for renal transplantation in adults. NICE technology appraisal guidance 85 (2004)
Laparoscopic insertion of peritoneal dialysis catheter. NICE interventional procedure guidance 208 (2007)
Laparoscopic live donor simple nephrectomy. NICE interventional procedure guidance 57 (2004)

Quality standards

Quality statements

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.

Description of 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 clinical guideline references

Recommendations on investigation of CKD are contained within section 1.1 (including key priority implementation 1.1.22) and recommendation 1.2.4 of NICE clinical guideline 73.

Data source

Structure
Local data collection.
Process
a) Local data collection. Contained within NICE clinical guideline 73 audit support, criterion 7.
Quality and Outcomes Framework (QOF) indicator DM 13: the percentage of patients with diabetes who have a record of micro-albuminuria 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).
CKD prevalence (stages 3–5) available from the Association of Public Health Observatories.

Definitions

NICE clinical guideline 73 states the following risk factors for CKD:
  • diabetes
  • hypertension
  • cardiovascular disease (ischaemic heart disease, chronic heart failure, peripheral vascular disease and cerebral vascular disease)
  • structural renal tract disease
  • kidney stones
  • prostatatic hypertrophy
  • multisystem disease with potential kidney involvement for example, systemic lupus erythematosus
  • family history of stage 5 CKD or hereditary kidney disease
  • opportunistic detection of haematuria or proteinuria.
People in these at-risk groups should be offered an eGFR and an albumin:creatinine ratio (ACR) check at least once per year.
Additionally, people prescribed drugs known to be nephrotoxic for example, calcineurin inhibitors and lithium, and those receiving long-term systemic non-steroidal anti-inflammatory drug treatment, should also have their eGFR monitored.
If none of these factors are present, age, gender, obesity or ethnicity should not be used as risk markers.
To ensure correct identification, NICE clinical guideline 73 recommendations include:
  • Quantify an ACR for people with an eGFR of 60 ml/min/1.73 m2 or more if CKD is strongly suspected.
  • Apply a correction factor for ethnicity to reported eGFR values (multiply eGFR by 1.21 for African-Caribbean ethnicity).
  • Advise people not to eat any meat in the 12 hours before having a blood test for eGFR.
  • Interpret the eGFR with caution in cases where there are extremes of muscle mass.
  • Ensure blood samples are received and processed by the laboratory within 12 hours of venepuncture.
  • Repeat a first eGFR result of less than 60 ml/min/1.73 m2 within 2 weeks.
  • Make an allowance for biological and analytical variability of serum creatinine when interpreting changes in renal function. Where possible, local laboratories should advise on the significance of change in serum creatinine results.
  • Use a rise in serum creatinine concentration of more than 20% to infer significant reduction in renal function where eGFR is 60 ml/min/1.73 m2 or more.
  • In people aged over 70 years, an eGFR in the range 45–59 ml/min/1.73 m2, if stable over time and without any other evidence of kidney damage, is unlikely to be associated with CKD-related complications.

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.

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.

Description of 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 clinical guideline references

NICE clinical guideline 73 recommendations 1.6.1 (key priority for implementation) and 1.2.4.

Data source

Structure
Local data collection.
Process
Local data collection. Contained within NICE clinical guideline 73 audit support, criterion 6.
The UK Renal Registry collects data from renal services on referral source and date.

Definitions

NICE clinical guideline 73 recommends that people in the following groups should normally be referred for specialist assessment:
  • Stage 4 and 5 CKD (with or without diabetes).
  • Higher levels of proteinuriaHigher levels of proteinuria: albumin:creatinine ratio (ACR) 70 mg/mmol or more, approximately equivalent to protein:creatinine ratio (PCR) 100 mg/mmol or more, or urinary protein excretion 1 g/24 h or more. unless known to be due to diabetes and already appropriately treated.
  • ProteinuriaProteinuria: ACR 30 mg/mmol or more, approximately equivalent to PCR 50 mg/mmol or more, or urinary protein excretion 0.5 g/24 h or more. together with haematuria.
  • Rapidly declining estimated glomerular filtration rate (eGFR)Rapidly declining eGFR: more than 5 ml/min/1.73 m2 in 1 year, or more than 10 ml/min/1.73 m2 within 5 years..
  • Hypertension that remains poorly controlled despite the use of at least four antihypertensive drugs at therapeutic doses (see ‘Hypertension: management of hypertension in adults in primary care' [NICE clinical guideline 34]).
  • People with, or suspected of having, rare or genetic causes of CKD.
  • Suspected renal artery stenosis.
NICE clinical guideline 73 cautions that in people aged over 70 years, an eGFR in the range 45–59 ml/min/1.73 m2, if stable over time and without any other evidence of kidney damage, is unlikely to be associated with CKD-related complications.

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 Renal 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.

Description of 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 clinical guideline references

Overarching principles of NICE clinical guideline 73 and NICE clinical guideline 114 (see ‘Person-centred care' and ‘Patient-centred care' sections). The Renal Association clinical practice guideline: planning, initiating and withdrawal of renal replacement therapy, recommendation 6.3.

Data source

Structure
Local data collection.
Process
a) Local data collection. Provision of information for patients and carers is contained within NICE clinical guideline 73 audit support, criteria 11 and 12.
b) Local data collection. Contained within The Renal Association clinical practice guideline: planning, initiating and withdrawal of renal replacement therapy, audit measure 18.

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.
Renal 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.
Information about NICE guidance, written specifically for parents and carers, is available for ‘Chronic kidney disease’ (NICE clinical guideline 73) and ‘Anaemia management in people with chronic kidney disease’ (NICE clinical guideline 114).
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 Renal 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 Renal PatientView. Additionally, Renal PatientView is only available in some renal units. People unable to or choosing not to access Renal PatientView should receive the same information from their renal unit via different means, such as a verbal discussion with a healthcare professional.

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.

Description of 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 clinical guideline references

The Renal Association clinical practice guideline: cardiovascular disease in CKD, recommendations 1.1 and 1.2.

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.

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.

Description of 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 clinical guideline references

NICE clinical guideline 73 recommendation 1.8.2.

Data source

Structure
Local data collection.
Process
Local data collection.
Outcome
Local data collection. Contained within NICE clinical guideline 73 audit support, criterion 10.

Definitions

NICE clinical guideline 73 defines higher levels of proteinuria in people with or without diabetes as albumin:creatinine ratio (ACR) 70 mg/mmol or more (approximately equivalent to protein:creatinine ratio [PCR] 100 mg/mmol or more, or urinary protein excretion 1 g/24 h or more) and microalbuminuria as ACR 2.5–30 mg/mmol in men and ACR 3.5–30 mg/mmol in women.
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.

Description of 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 clinical guideline references

NICE clinical guideline 73 recommendation 1.5.1 (key priority for implementation).

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. Annual estimated glomerular filtration rate (eGFR) testing and identification of progressive CKD contained within NICE clinical guideline 73 audit support, criteria 3 and 8.

Definitions

NICE clinical guideline 73 defines progressive CKD as a decline in eGFR of more than 5 ml/min/1.73 m2 within 1 year, or more than 10 ml/min/1.73 m2 within 5 years.
Progression of proteinuria includes:
  • development of microalbuminuria in those with diabetes
  • development of proteinuria (ACR 30 mg/mmol or more [PCR 50 mg/mmol or more]) in those with or without diabetes
  • increase in proteinuria to ACR 70 mg/mmol or more (PCR 100 mg/mmol or more) in those with or without diabetes.

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.

Description of 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 clinical guideline references

The Renal Association clinical practice guideline: Acute kidney injury, recommendation 3.1.

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.

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.

Description of 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 clinical guideline references

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 4) 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.
Outcome
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 quality statement 11 – ‘Transplantation – pre-emptive' and 12 – ‘Transplantation – on dialysis'.

Description of 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 clinical guideline references

The Renal Association clinical practice guideline: planning, initiating and withdrawal of renal replacement therapy, recommendation 3.1.

Data source

Structure
Local data collection.
Process
Local data collection. Contained within The Renal Association clinical practice guideline: planning, initiating and withdrawal of renal replacement therapy, audit measures 7–9.
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.

Description of 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 clinical guideline references

The Renal Association clinical practice guideline: planning, initiating and withdrawal of renal replacement therapy, recommendation 5.2.

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.

Transplantation – pre-emptive

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 supported to receive a pre-emptive kidney transplant before they need dialysis, if they are medically suitable.

Quality measure

Structure
a) Evidence of local arrangements to ensure that people with CKD are supported to receive a pre-emptive kidney transplant before they need dialysis, if they are medically suitable.
b) Evidence of local arrangements to ensure that people with progressive CKD have their suitability for kidney transplantation assessed at the earliest opportunity.
Outcome
Proportion of people with CKD who are medically suitable, receiving a pre-emptive kidney transplant before they need dialysis.
Numerator – the number of people in the denominator receiving a pre-emptive kidney transplant before they need dialysis.
Denominator – the number of people medically suitable for pre-emptive kidney transplantation.

Description of what the quality statement means for each audience

Service providers ensure they support people with CKD to receive pre-emptive kidney transplantation before they need dialysis, if they are medically suitable.
Healthcare professionals ensure they assess people with CKD for pre-emptive kidney transplantation at the earliest opportunity and support them to receive a transplant before they need dialysis, if they are medically suitable.
Commissioners ensure they commission services that support people with CKD to receive pre-emptive kidney transplantation before they need dialysis, if they are medically suitable.
People with CKD who are medically suitable are given support to receive a kidney transplant before they need dialysis.

Source clinical guideline references

The Renal Association clinical practice guideline: assessment of the potential kidney transplant recipient, recommendation 1.3.

Data source

Structure
Local data collection. The UK Renal Registry collects data on the date of assessment for transplant suitability and the date of first established renal failure treatment.
Outcome
Local data collection. Hospital Episode Statistics (HES) contains data on kidney transplantation. The Office of population censuses and survey classification of surgical operations and procedures (OPCS-4) codes for this are M01 Transplantation of kidney (subcategories 1–5, 8, 9) and M17 Interventions associated with transplantation of kidney (subcategories 1–5, 8, 9), which includes live kidney donor screening. The UK Renal Registry collects data on the date of transplant and date of first established renal failure treatment. Also contained within The Renal Association clinical practice guideline: assessment of the potential kidney transplant recipient, audit criteria 4 and Planning, initiating and withdrawal of renal replacement therapy, audit measure 4.

Definitions

Pre-emptive transplantation may be from a cadaveric or living donor; living donor is preferred.
Medically suitable patients should include those whose transplant workup has been delayed by poor access to appropriate investigations such as coronary angiography.

Transplantation – on dialysis

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 on dialysis are supported to receive a kidney transplant, if they are medically suitable.

Quality measure

Structure
a) Evidence of local arrangements to ensure that people with CKD on dialysis are supported to receive a kidney transplant, if they are medically suitable.
b) Evidence of local arrangements to ensure that people with CKD on dialysis have their suitability for kidney transplantation assessed at the earliest opportunity.
Process
a) Proportion of people with CKD starting dialysis in a planned way who were medically suitable and active on the kidney transplant waiting list for 6 months or more before starting dialysis.
Numerator – the number of people in the denominator active on the kidney transplant waiting list for 6 months or more at the start of dialysis.
Denominator – the number of people with CKD starting dialysis in a planned way and medically suitable for transplantation.
b) Proportion of people receiving dialysis which was started in an unplanned way who are medically suitable and active on the kidney transplant waiting list within 12 months of starting dialysis.
Numerator – the number of people in the denominator active on the kidney transplant waiting list within 12 months of starting dialysis.
Denominator – the number of people receiving dialysis which was started in an unplanned way, medically suitable for kidney transplantation.
Outcome
Proportion of people with CKD previously or currently on dialysis who are medically suitable for, and who receive, a kidney transplant.
Numerator – the number of people in the denominator receiving a kidney transplant.
Denominator – the number of people with CKD previously or currently on dialysis, medically suitable for a kidney transplant.

Description of what the quality statement means for each audience

Service providers ensure that they support people with CKD on dialysis to receive a kidney transplant, if they are medically suitable.
Healthcare professionals ensure they assess people with CKD on dialysis for kidney transplantation at the earliest opportunity and support them to receive a transplant, if they are medically suitable.
Commissioners ensure they commission services that support people with CKD on dialysis to receive a kidney transplant, if they are medically suitable.
People with CKD on dialysis who are medically suitable are given support to receive a kidney transplant.

Source clinical guideline references

The Renal Association clinical practice guideline: assessment of the potential kidney transplant recipient, recommendation 1.3.

Data source

Structure
Local data collection. The UK Renal Registry collects data on the date of assessment for transplant suitability and the date of first established renal failure treatment. Transplant status also contained within The Renal Association clinical practice guideline: assessment of the potential kidney transplant recipient, audit criteria 6.
Process
The UK Renal Registry collects data on transplant waiting list status (including date) and renal treatment modality. Also contained within The Renal Association clinical practice guideline: assessment of the potential kidney transplant recipient, audit criteria 3 and 5.
Outcome
Hospital Episode Statistics (HES) contains data on kidney transplantation. The Office of population censuses and survey classification of surgical operations and procedures (OPCS-4) codes for this are M01 Transplantation of kidney (subcategories 1–5, 8, 9) and M17 Interventions associated with transplantation of kidney (subcategories 1–5, 8, 9), which includes live kidney donor screening. The UK Renal Registry collects data on the date of transplant and renal treatment modality.

Dialysis access

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 kidney failure start dialysis with a functioning arteriovenous fistula or peritoneal dialysis catheter in situ.

Quality measure

Structure
Evidence of local arrangements to ensure that catheter insertion for peritoneal dialysis is performed at least 2 weeks before dialysis start and, where clinically indicated, a functioning arteriovenous fistula is in situ when people start haemodialysis.
Process
a) Proportion of people starting long-term haemodialysis more than 90 days after referral who start dialysis with a functioning arteriovenous fistula or other vascular access with documented valid clinical reasons for the need for non-fistula access.
Numerator – the number of people in the denominator with a functioning arteriovenous fistula or other vascular access with documented valid clinical reasons for the need for non-fistula access.
Denominator – the number of people starting long-term haemodialysis more than 90 days after referral.
b) Proportion of people starting long-term haemodialysis within 90 days of referral with intravenous vascular access who have a planned date for arteriovenous fistula surgery or other permanent vascular access with documented clinical reasons for the need for non-fistula access.
Numerator – the number of people in the denominator with a planned date for arteriovenous fistula surgery or other permanent vascular access with documented clinical reasons for the need for non-fistula access.
Denominator – the number of people starting long-term haemodialysis within 90 days of referral with intravenous vascular access.
c) Proportion of people who have a peritoneal catheter inserted at least two weeks before starting peritoneal dialysis.
Numerator – the number of people in the denominator with a peritoneal catheter insertion performed at least 2 weeks before starting dialysis.
Denominator – the number of people starting peritoneal dialysis.
Outcome
a) Proportion of people starting haemodialysis treatment who start dialysis with a functioning arteriovenous fistula.
Numerator – the number of people in the denominator with a functioning arteriovenous fistula.
Denominator – the number of people starting haemodialysis.
Consideration should be given to The Renal Association audit standard of 65% for outcome a).
b) Proportion of people on haemodialysis treatment who receive dialysis via a functioning arteriovenous fistula.
Numerator – the number of people in the denominator with a functioning arteriovenous fistula (including people who started dialysis with other vascular access who now have a functioning arteriovenous fistula).
Denominator – the number of people receiving haemodialysis.
Consideration should be given to an audit standard of 75% for outcome b).
c) Staphylococcus aureus (MRSA and MSSA) bacteraemia rate in people under the care of renal services.
d) Peritonitis rate in people receiving peritoneal dialysis.
e) Other dialysis-associated infection rates.

Description of what the quality statement means for each audience

Service providers ensure that systems are in place to perform catheter insertion at least 2 weeks before people start peritoneal dialysis and, where clinically indicated, to establish a functioning arteriovenous fistula in people starting (and receiving if late referral) haemodialysis.
Healthcare professionals ensure they perform catheter insertion at least 2 weeks before people start peritoneal dialysis and establish a functioning arteriovenous fistula in people starting (and receiving if late referral) haemodialysis, where clinically indicated.
Commissioners ensure services perform catheter insertion at least 2 weeks before people start peritoneal dialysis and, where clinically indicated, services establish a functioning arteriovenous fistula in people starting (and receiving if late referral) haemodialysis.
People with CKD starting dialysis are prepared in advance either by connecting an artery to a vein (arteriovenous fistula) usually in the forearm, or by inserting a tube (a catheter) into the abdomen, depending on the situation and type of dialysis.

Source clinical guideline references

The Renal Association clinical practice guideline: vascular access for haemodialysis, recommendations 1.1 and 1.2; and Peritoneal access, recommendation 2.1.

Data source

Structure
Local data collection.
Process
Local data collection. The National Kidney Care Audit of vascular access examines, at a patient level, the type of vascular access used at first dialysis. Hospital Episode Statistics (HES) contains data on placement of ambulatory and other apparatus for compensation for renal failure. The Office of population censuses and survey classification of surgical operations and procedures (OPCS-4) codes for this are X41 (subcategories 1, 2, 8 and 9) and X42 (subcategories 1, 8 and 9). The UK Renal Registry collects data on date of referral for access construction and type of dialysis access as well as date of referral to renal services and date of first established renal failure treatment.
Outcome
a) and b) as above.
c) NHS Indicators for quality improvement (IQI) LT28: Rate of MRSA bacteraemia in patients in established renal failure by renal centre, per 100 prevalent patients (only retrospective data available at the time of publication). As part of its mandatory surveillance scheme, the Health Protection Agency collects, by trust, Staphylococcus aureus (MRSA) bacteraemia infection rates. The UK Renal Registry extracted the MRSA data at renal unit level for the previous 2 years (2007 and 2008).
a), b) and c) are also contained within The Renal Association clinical practice guideline: vascular access for haemodialysis, audit measures 1 and 3.
d) Contained within The Renal Association clinical practice guideline: peritoneal access, audit measure 2. Peritonitis diagnoses are collected by the UK Renal Registry.
e) Dialysis access complications are collected by the UK Renal Registry.

Definitions

Clinical reasons for not using an arteriovenous fistula when haemodialysis is first started include:
  • Person with CKD known to nephrology team for 90 days or less. However, people receiving urgent, temporary access should be considered for a fistula at the earliest opportunity.
Clinical reasons for not using an arteriovenous fistula at any stage of haemodialysis may include:
  • lack of suitable blood vessels
  • secondary failure
  • individual preference of the person with CKD following balanced discussion of risks and complications with healthcare professional.

Best possible dialysis

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 on long-term dialysis receive the best possible therapy, incorporating regular and frequent application of dialysis and ideally home-based or self-care dialysis.

Quality measure

Structure
a) Evidence of local arrangements to ensure that people on long-term dialysis receive the best possible therapy, incorporating regular and frequent application of dialysis and ideally home or self-care dialysis.
b) Evidence of local arrangements to ensure that people on long-term dialysis are reviewed regularly for the best possible therapy.
Process
a) Proportion of people on long-term dialysis who dialyse at home or via self-care.
Numerator – the number of people in the denominator dialysing at home or via self-care.
Denominator – the number of people on long-term dialysis.
b) Proportion of people on long-term haemodialysis who receive either three sessions of haemodialysis per week of at least 4 hours duration or more frequent haemodialysis.
Numerator – the number of people in the denominator receiving either three sessions of haemodialysis per week of at least 4 hours duration or more frequent haemodialysis.
Denominator – the number of people on long-term haemodialysis.
c) Proportion of people on peritoneal dialysis who are on automated peritoneal dialysis (APD).
Numerator – the number of people in the denominator on APD.
Denominator – the number of people on peritoneal dialysis.

Description of what the quality statement means for each audience

Service providers ensure that systems are in place to provide people on long-term dialysis with the best possible therapy, incorporating regular and frequent application of dialysis and ideally home-based or self-care dialysis.
Healthcare professionals ensure they review people on long-term dialysis for and offer the best possible therapy incorporating regular and frequent application of dialysis, and support them to receive home or self-care dialysis if possible.
Commissioners ensure they commission services that support people on long-term dialysis to receive the best possible therapy, incorporating regular and frequent application of dialysis and ideally home-based or self-care dialysis.
People on long-term dialysis receive the best possible care, which is regular and frequent dialysis sessions that might be carried out at home.

Source clinical guideline references

The Renal Association clinical practice guidelines: planning, initiating and withdrawal of renal replacement therapy, recommendations 3.5 and 3.6, Haemodialysis 5.1 and 5.4 and Peritoneal dialysis 3.2, 3.3 (rationale) and 4.2. NICE technology appraisal 48 recommendation 1.1.

Data source

Structure
Local data collection.
Process
Local data collection. The UK Renal Registry collects data on renal treatment modality and renal dialysis episodes per week.

Definitions

Best-possible haemodialysis comprises either 3 sessions per week of at least 4 hours duration or more frequent dialysis, ideally at home.
People choosing peritoneal dialysis should be offered a choice between APD (assisted where appropriate) and continuous ambulatory peritoneal dialysis (CAPD).

Patient transport

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 receiving haemodialysis or training for home therapies who are eligible for transport, have access to an effective and efficient transport service.

Quality measure

Structure
a) Evidence of local transport arrangements to ensure that people with CKD receiving haemodialysis or training for home therapies who are eligible for transport, have access to an effective and efficient transport service.
b) Evidence of local arrangements to act upon the latest patient satisfaction results from the National Kidney Care 2010 Patient Transport Audit.
Process
a) Proportion of people with CKD training for home therapies, who are eligible for and require transport, who have access to effective and efficient transport.
Numerator – the number of people in the denominator with access to effective and efficient transport.
Denominator – the number of people training for home therapies eligible for and requiring transport.
b) Proportion of people receiving haemodialysis in a renal unit or hospital who have been reviewed for transport eligibility in the previous 6 months.
Numerator – the number of people in the denominator reviewed for transport eligibility in the previous 6 months.
Denominator – the number of people receiving haemodialysis in a renal unit or hospital.
c) Proportion of people receiving haemodialysis in a renal unit or hospital, who are eligible for and require transport, and who are collected from home within 30 minutes of their allotted time.
Numerator – the number of people in the denominator collected from home within 30 minutes of their allotted time.
Denominator – the number of people receiving haemodialysis in a renal unit or hospital, eligible for and requiring transport.
d) Proportion of people receiving haemodialysis in a renal unit or hospital, who are eligible for and require transport, and who are collected to return home within 30 minutes of finishing dialysis.
Numerator – the number of people in the denominator collected to return home within 30 minutes of finishing dialysis.
Denominator – the number of people receiving haemodialysis in a renal unit or hospital, eligible for and requiring transport.

Description of what the quality statement means for each audience

Transport service providers ensure they provide effective and efficient transport for people receiving haemodialysis in a renal unit or hospital or training for home therapies, who are eligible for transport.
Healthcare service providers ensure that haemodialysis treatments in a renal unit or hospital and training for home therapies take place on time so that transport schedules can be upheld.
Healthcare professionals assess people's eligibility for transport if they are receiving haemodialysis in a renal unit or hospital or training for home therapies. They review this when circumstances change and help to ensure that haemodialysis treatments, and training for home therapies, take place on time so that transport schedules are upheld.
Commissioners commission services that provide effective and efficient transport for eligible people receiving haemodialysis in a renal unit or hospital, or training for home therapies.
People receiving dialysis in a renal unit or hospital, or training for home therapies, who are eligible for assistance with transport can obtain efficient and reliable transport to and from the unit or hospital.

Source clinical guideline references

The Renal Association clinical practice guideline: haemodialysis, recommendations 1.4 and 9.2.

Data source

Structure
The National Kidney Care 2010 Patient Transport Audit examines, at a patient level, experience of travelling to a renal unit for treatment, including wait times, journey times and whether or not transport is free.
Process
a), b) and c) The National Kidney Care 2010 Patient Transport Audit examines, at a unit level, how patient transport services are provided. This includes providing published criteria describing eligibility for free and appropriate transport, and regular review of patients' needs. The UK Renal Registry collects data on patient transport including the date and time of pick up, the date and time the patient is taken off the machine and the date and time of return pick up. d) also contained within The Renal Association clinical practice guideline: haemodialysis, audit measure 2.

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Effective interventions library

Successful effective interventions library details

Implementation

Education and learning

NICE produces resources for individual practitioners, teams and those with a role in education to help improve and assess users' knowledge of relevant NICE guidance and its application in practice.

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

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Supporting information

Frequency of monitoring of GFR (number of times per year, by GFR and ACR category) for people with, or at risk of, CKD

ACR categories (mg/mmol), description and range
Increasing risk ↓
A1 <3
Normal to mildly increased
A2 3–30
Moderately increased
A3 >30
Severely increased
GFR categories (ml/min/1.73m2), description and range
G1 ≥90
Normal and high
≤1
1
≥1
G2 60–89
Mild reduction related to normal range for a young adult
≤1
1
≥1
G3a 45–59
Mild–moderate reduction
1
1
2
G3b 30–44
Moderate–severe reduction
≤2
2
≥2
G4 15–29
Severe reduction
2
2
3
G5 <15
Kidney failure
4
≥4
≥4
Increasing risk
NB: ACR is an important indicator of cardiovascular risk and progression.
Adapted with permission from Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group (2013) KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney International (Suppl. 3): 1–150

Glossary

Albumin:creatinine ratio.
Assisted automated peritoneal dialysis.
Automated peritoneal dialysis.
Continuous ambulatory peritoneal dialysis.
Chronic kidney disease. Defined as abnormalities of kidney function or structure present for more than 3 months, with implications for health. This includes all people with markers of kidney damage and those with a glomerular filtration rate of less than 60 ml/min/1.73 m2 on at least 2 occasions separated by a period of at least 90 days (with or without markers of kidney damage).
Chronic Kidney Disease Epidemiology Collaboration.
Estimated glomerular filtration rate (without indicating the method of estimation).
An estimation of glomerular filtration rate using serum creatinine.
An estimation of glomerular filtration rate using cystatin C.
Glomerular filtration rate.
Isotope dilution mass spectrometry.
This includes albuminuria (ACR more than 3 mg/mmol), urine sediment abnormalities, electrolyte and other abnormalities due to tubular disorders, abnormalities detected by histology, structural abnormalities detected by imaging and a history of kidney transplantation.
Non-steroidal anti-inflammatory drugs.
Protein:creatinine ratio.
Parathyroid hormone.
A drug that blocks or inhibits the renin–angiotensin–aldosterone system including angiotensin-converting enzyme (ACE) inhibitors, angiotensin-receptor blockers (ARBs), direct renin inhibitors and aldosterone antagonists.
A drug that blocks or inhibits the renin–angiotensin system including angiotensin-converting enzyme (ACE) inhibitors, angiotensin-receptor blockers (ARBs) and direct renin inhibitors. This group of drugs does not include aldosterone antagonists.

Paths in this pathway

Pathway created: May 2011 Last updated: September 2014

© NICE 2014

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