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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

27 November 2014 Renal replacement therapy services (NICE quality standard 72) added 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

27 November 2014 Renal replacement therapy services (NICE quality standard 72) added 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

Chronic kidney disease quality standard

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

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.

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.

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.

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.

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.

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]

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.

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.

Transplantation – on dialysis

This quality statement is taken from the renal replacement therapy services quality standard. The quality standard defines clinical best practice in renal replacement therapy services and should be read in full.

Quality statement

Adults on dialysis are offered a kidney transplant, if they are medically suitable.

Rationale

Transplant survival has been shown to be negatively influenced by the duration of dialysis before transplantation. Therefore, it is important that adults who are on dialysis continue to be supported to receive a kidney transplant if it is medically suitable for them. This includes adults for whom pre‑emptive transplantation was not possible and also those starting dialysis in an unplanned way.

Quality measures

Structure
a) Evidence of local arrangements to ensure that adults on dialysis have their suitability for kidney transplantation assessed at the earliest opportunity.
Data source: 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 is also contained within The Renal Association's Clinical practice guideline: assessment of the potential kidney transplant recipient, audit criterion 6.
b) Evidence of local arrangements to ensure that adults on dialysis receive a kidney transplant, if they are medically suitable.
Data source: 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 is also contained within The Renal Association's Clinical practice guideline: assessment of the potential kidney transplant recipient, audit criterion 6.
Process
a) Proportion of adults receiving dialysis that was started in a planned way (excluding those presenting late in advanced chronic kidney disease) who are medically suitable and active on the kidney transplant waiting list within 6 months of starting dialysis.
Numerator – the number in the denominator active on the kidney transplant waiting list within 6 months of starting dialysis.
Denominator – the number of adults receiving dialysis that was started in a planned way who are medically suitable for kidney transplantation.
b) Proportion of adults receiving dialysis that 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 in the denominator active on the kidney transplant waiting list within 12 months of starting dialysis.
Denominator – the number of adults receiving dialysis that was started in an unplanned way who are medically suitable for kidney transplantation.
Data source: The UK Renal Registry collects data on transplant waiting list status (including date) and renal treatment modality. Also contained within The Renal Association's Clinical practice guideline: assessment of the potential kidney transplant recipient, audit criteria 3 and 5.
c) Proportion of adults previously or currently on dialysis who are medically suitable for, and who receive, a kidney transplant.
Numerator – the number in the denominator who receive a kidney transplant.
Denominator – the number of adults previously or currently on dialysis, who are medically suitable for a kidney transplant.
Data source: The Health and Social Care Information Centre Hospital Episode Statistics contains data on kidney transplantation. The Office of population censuses and survey classification of surgical operations and procedures (4th revision) 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.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (specialist renal centres) ensure that they offer a kidney transplant to adults on dialysis, if they are medically suitable.
Healthcare professionals ensure that they assess adults on dialysis for kidney transplant suitability and offer a transplant to adults, if they are medically suitable.
Commissioners (NHS England area teams) ensure that they commission services that offer adults on dialysis a kidney transplant, if they are medically suitable.

What the quality statement means for patients, service users and carers

Adults who are already on dialysis are offered a kidney transplant as soon as possible, if it is a suitable treatment for them.
Source guidance

Dialysis access preparation

This quality statement is taken from the renal replacement therapy services quality standard. The quality standard defines clinical best practice in renal replacement therapy services and should be read in full.

Quality statement

Adults with established kidney failure who are starting planned dialysis have a functioning arteriovenous fistula or peritoneal dialysis catheter.

Rationale

Dialysis access is an increasingly important marker of clinical care. Where clinically indicated, functioning arteriovenous fistulas are regarded as the best form of vascular access for adults receiving haemodialysis. This is because they last longer, need less maintenance and carry less risk of complications than other types of vascular access. Whenever possible, a working fistula should be established for adults starting haemodialysis treatments.
Appropriate planning allows sufficient time to establish a working fistula for haemodialysis or to insert a peritoneal catheter for peritoneal dialysis and avoids the need for emergency access.

Quality measures

Structure
Evidence of local arrangements to ensure that catheter insertion for peritoneal dialysis is performed at least 2 weeks before peritoneal dialysis starts or, where clinically indicated, via a functioning arteriovenous fistula when adults start haemodialysis.
Data source: Local data collection.
Process
a) Proportion of adults with established kidney failure 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 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 adults with established kidney failure more than 90 days after referral who start dialysis.
Data source: Local data collection.
b) Proportion of adults 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 in the denominator 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.
Denominator – the number of adults starting long‑term haemodialysis within 90 days of referral with intravenous vascular access.
Data source: Local data collection.
c) Proportion of adults starting peritoneal dialysis who have a peritoneal catheter inserted at least 2 weeks before starting dialysis.
Numerator – the number in the denominator who have a peritoneal catheter inserted at least 2 weeks before starting dialysis.
Denominator – the number of adults starting peritoneal dialysis.
Data source: Local data collection.
Outcomes
a) Staphylococcus aureus (MRSA and MSSA) bacteraemia rate in adults under the care of renal services.
Data source: Local data collection.
b) Dialysis‑associated infection rates.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (specialist renal centres) ensure that systems are in place for a functioning arteriovenous fistula to be established, if clinically indicated, or a peritoneal dialysis catheter inserted in adults with established kidney failure who are starting planned dialysis. Systems should be in place for catheter insertion to be carried out at least 2 weeks before peritoneal dialysis starts.
Healthcare professionals ensure that a functioning arteriovenous fistula is established, if clinically indicated, or a peritoneal dialysis catheter is inserted in adults with established kidney failure who are starting planned dialysis. Catheter insertion should be carried out at least 2 weeks before peritoneal dialysis starts.
Commissioners (NHS England area teams) ensure that services establish functioning arteriovenous fistulas, if clinically indicated, or insert peritoneal dialysis catheters in adults with established kidney failure who are starting planned dialysis. Catheter insertion should be carried out at least 2 weeks before peritoneal dialysis starts.

What the quality statement means for patients, service users and carers

Adults starting dialysis have a procedure carried out in advance to prepare them for dialysis. This should be done by connecting an artery to a vein (arteriovenous fistula) usually in the forearm, or by inserting a tube (a peritoneal catheter) into the abdomen, depending on the situation and type of dialysis.

Source guidance

Home-based dialysis

This quality statement is taken from the renal replacement therapy services quality standard. The quality standard defines clinical best practice in renal replacement therapy services and should be read in full.

Quality statement

Adults who need long‑term dialysis are offered home‑based dialysis.

Rationale

All adults should be encouraged to carry out home‑based dialysis if possible. Research suggests that given appropriate education and choice, many adults would choose home‑based dialysis (peritoneal dialysis or home haemodialysis) in preference to hospital‑based dialysis because of improved experience of care and quality of life. However, this is not reflected in the actual number of people receiving dialysis at home.

Quality measures

Structure
Evidence of local arrangements to ensure that adults on long‑term dialysis are offered the option of home‑based dialysis.
Data source: Local data collection.
Process
Proportion of adults on long‑term dialysis who carry out home‑based dialysis.
Numerator – the number in the denominator who carry out dialysis at home.
Denominator – the number of adults on long‑term dialysis.
Data source: Local data collection. The UK Renal Registry collects data on renal treatment modality and renal dialysis episodes per week.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (specialist renal centres) ensure that systems are in place to provide adults on long‑term dialysis with home‑based dialysis.
Healthcare professionals ensure that they review people on long‑term dialysis, offer them home‑based dialysis if possible, and provide support.
Commissioners (NHS England area teams) ensure that they commission services that offer adults on long‑term dialysis the opportunity to receive home‑based dialysis if possible, and that provide support.

What the quality statement means for patients, service users and carers

Adults on long‑term dialysis are offered the option of having dialysis at home, which they can carry out by themselves.

Source guidance

Patient transport

This quality statement is taken from the renal replacement therapy services quality standard. The quality standard defines clinical best practice in renal replacement therapy services and should be read in full.

Quality statement

Adults using transport services to attend for dialysis are collected from home within 30 minutes of the allotted time and collected to return home within 30 minutes of finishing dialysis.

Rationale

Patient transport is an essential part of patient experience for adults receiving hospital‑ or satellite‑based dialysis, which requires frequent travel between their home and the treatment centre. Poor transport can undermine good dialysis care and can have a major impact on a person's quality of life. This also applies to adults who are training for home‑based therapies and may need to travel to a regional renal centre.

Quality measures

Structure
Evidence of local arrangements to ensure that adults using transport services to attend for dialysis are collected from home within 30 minutes of the allotted time and collected to return home within 30 minutes of finishing dialysis.
Data source: Local data collection.
Process
a) Proportion of adults using transport services to attend for dialysis who are collected from home within 30 minutes of their allotted time.
Numerator – the number in the denominator who are collected from home within 30 minutes of their allotted time.
Denominator – the number of adults using transport services to attend for dialysis.
Data source: The patient transport survey (2010) examines, at a unit level, the provision of patient transport services. 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.
b) Proportion of adults using transport services to attend for dialysis who are collected to return home within 30 minutes of finishing dialysis.
Numerator – the number in the denominator collected to return home within 30 minutes of finishing dialysis.
Denominator – the number of adults using transport services to attend for dialysis.
Data source: The patient transport survey (2010) examines, at a unit level, the provision of patient transport services. 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. Also contained within The Renal Association's Clinical practice guideline: haemodialysis, audit measure 2.
Outcomes
(a) Patient satisfaction.
Data source: Local data collection. Patient transport survey (2010).
(b) Missed appointments.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (transport service providers, specialist renal units and hospitals) ensure that they provide reliable transport for adults receiving dialysis in a treatment centre or who are training for home‑based dialysis.
Specialist renal units and hospitals ensure that dialysis treatments and training for home‑based dialysis take place on time so that transport schedules can be upheld.
Healthcare professionals ensure that dialysis treatments and training for home‑based dialysis take place on time so that transport schedules are upheld.
Commissioners (clinical commissioning groups) commission services that provide reliable transport for adults receiving dialysis in a specialist renal unit or hospital, or who are training for home‑based dialysis. They review local transport arrangements, including the use of ambulances, taxis, volunteer drivers, and other private transport providers, and determine whether appropriate systems and processes are in place, and if any service redesign is necessary.

What the quality statement means for patients, service users and carers

Adults receiving dialysis or training for dialysis at home in a specialist renal unit or hospitals are provided with reliable transport to and from the unit or hospital. They should not have to wait for more than 30 minutes to be picked up or wait for more than 30 minutes to return home.

Source guidance

Equality and diversity considerations

For adults using transport services to attend for dialysis, provision should be available to facilitate access to services for those who may find it difficult to travel long distances due to disability, financial barriers or other characteristics.

Education programmes

This quality statement is taken from the renal replacement therapy services quality standard. The quality standard defines clinical best practice in renal replacement therapy services and should be read in full.

Quality statement

Adults preparing for or receiving renal replacement therapy, and their family members or carers, undertake individualised education programmes at specialist renal centres.

Rationale

Renal education programmes can improve patients' (and their family members' or carers') knowledge and understanding of the condition, and can help people to choose the treatment options that are most suitable for them. The benefits of pre‑dialysis education include improved wellbeing and physical functioning, as well as positively contributing to better planning and successfully starting dialysis, improved vascular access, delaying the need for starting dialysis and an increased likelihood of patients choosing self‑care.
Evidence also suggests that education is important to ensure that these benefits are maintained and that the person's involvement (including full participation of families and/or carers) in their care and treatment choices is optimised. This includes adults who start dialysis in an unplanned way.

Quality measures

Structure
Evidence that adults preparing for or receiving renal replacement therapy, and their family members or carers, undertake individualised education programmes at specialist renal centres.
Data source: Local data collection.
a) Proportion of adults preparing for renal replacement therapy who undertake individualised education programmes at specialist renal centres.
Numerator – the number in the denominator who undertake individualised education programmes at specialist renal centres.
Denominator – the number of adults preparing for renal replacement therapy.
Data source: Local data collection.
b) Proportion of adults receiving renal replacement therapy who undertake individualised education programmes at specialist renal centres.
Numerator – the number in the denominator who undertake individualised education programmes at specialist renal centres.
Denominator – the number of adults receiving renal replacement therapy.
Data source: Local data collection.
c) Proportion of family members or carers of adults preparing for renal replacement therapy who undertake individualised education programmes at specialist renal centres.
Numerator – the number in the denominator who undertake individualised education programmes at specialist renal centres.
Denominator – the number of family members or carers of adults preparing for renal replacement therapy.
Data source: Local data collection.
d) Proportion of family members or carers of adults receiving renal replacement therapy who undertake individualised education programmes at specialist renal centres.
Numerator – the number in the denominator who undertake individualised education programmes at specialist renal centres.
Denominator – the number of family members or carers of adults receiving renal replacement therapy.
Data source: Local data collection.
Outcome
Patient satisfaction feedback from adults preparing for or receiving renal replacement therapy (and their family members and carers) about their individualised education programmes on renal replacement therapy at specialist renal centres.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (specialist renal centres) ensure that they provide individualised education programmes for adults who are preparing for or receiving renal replacement therapy, and their family members or carers.
Healthcare professionals ensure that they offer individualised education programmes to adults who are preparing for or receiving renal replacement therapy, and their family members or carers.
Commissioners (NHS England area teams) ensure that individualised education programmes are in place with clear referral pathways for adults preparing for or receiving renal replacement therapy, and their family members or carers.

What the quality statement means for patients, service users and carers

Adults who are preparing for or receiving renal replacement therapy (including those who start dialysis in an unplanned way), and their family members or carers, are offered an education course to improve their knowledge and understanding of the condition, and to help them choose the most appropriate options for treatment. The course will be adapted to the person's situation and preferences for learning, and will continue after treatment has started.

Source guidance

Definitions of terms used in this quality statement

Education programmes
Education programmes are aimed at improving patient and (if appropriate) family or carer knowledge, understanding of the condition and helping to choose from among the treatment options. The education programme should be tailored to the needs of the individual and be designed to support patient choice.
A range of teaching methods can be used within 1 session to allow learning to take place irrespective of the learning style. The information should be specifically designed to support decision‑making regarding treatment options. This should be relevant to the person, their disease stage and treatment options available to them, with the method, scale, pace and scope of the delivery being suited to the individual's learning style, capacity and preferences.
A variety of approaches should be available. These include:
  • individual conversations
  • group work
  • written materials
  • DVD/CDs and Internet resources
  • decision‑making aids
  • access to expert patients with appropriate training.
The education programme should be offered to adults who are preparing for renal replacement therapy (adults with severe chronic kidney disease [stage 5 and progressive stage 4]), and to adults who present late and start dialysis in an unplanned way, and to their families or carers, if appropriate.
The programme should also provide continuing education for adults receiving dialysis, and their family members or carers (if appropriate), with the aims of reviewing the original choice made by the patient, optimising patient involvement in their own care, improving treatment adherence, and fostering good communication and collaborative relationships with caregivers.
[Adapted from The Renal Association (2014) Clinical practice guideline: planning, initiating and withdrawal of renal replacement therapy, recommendations 4.1, 4.2 and 4.3 including rationale]

Equality and diversity considerations

Information should be provided in an accessible format (particularly for people with physical, sensory or learning disabilities and those who do not speak or read English) and educational materials should be translated where appropriate.

Transplantation – rapid access to a specialist histopathology service

This quality statement is taken from the renal replacement therapy services quality standard. The quality standard defines clinical best practice in renal replacement therapy services and should be read in full.

Quality statement

Adults who have a suspected acute rejection episode have a transplant kidney biopsy carried out and reported on within 24 hours.

Rationale

Adults who have had a kidney transplant who are suspected of having an acute rejection episode should have a biopsy within 24 hours in order to inform treatment decisions. It is important that treatment for acute rejection is guided by the transplant biopsy results and is started as soon as possible. This relies on rapid access to a specialist histopathology service so that the transplant dysfunction can be established.

Quality measures

Structure
Evidence of local arrangements to ensure that adults who have a suspected acute rejection episode have a transplant kidney biopsy carried out and reported on within 24 hours.
Data source: Local data collection.
Process
Proportion of adults with a suspected acute rejection episode who have a transplant kidney biopsy carried out and reported on within 24 hours.
Numerator – the number in the denominator who have a transplant kidney biopsy carried out and reported on within 24 hours.
Denominator – the number of adults with a suspected acute rejection episode.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (specialist histopathology services) ensure that they provide rapid access (within 24 hours) to transplant kidney biopsies so that transplant dysfunction can be established quickly after a suspected acute rejection.
Healthcare professionals ensure that adults who have a suspected acute rejection episode receive a transplant kidney biopsy that is carried out and reported on within 24 hours.
Commissioners (clinical commissioning groups and NHS England area teams) ensure that they commission services for adults who have a suspected acute rejection episode to have a transplant kidney biopsy that is carried out and reported on within 24 hours.

What the quality statement means for patients, service users and carers

Adults who have had a kidney transplant who may have had an 'acute transplant rejection' (which is when the body's immune system attacks the donated kidney) have a procedure called a kidney biopsy to remove, test and report on a small sample of the kidney. This should be carried out within 24 hours of the possible rejection.

Source guidance

Haemodialysis access – monitoring and maintaining vascular access

This quality statement is taken from the renal replacement therapy services quality standard. The quality standard defines clinical best practice in renal replacement therapy services and should be read in full.

Quality statement

Adults receiving haemodialysis have their vascular access monitored and maintained using systematic assessment.

Rationale

Maintaining vascular access using systematic assessment (clinical monitoring on each access use and consideration of advanced surveillance) ensures that it works well for as long as possible and so prevents obstruction, infection and other complications such as rupture. Early recognition of a failing access is crucial to inform appropriate intervention, to avoid the need for emergency access and to plan for further access surgery in a timely way. Urgent access‑related complications should be treated by a multidisciplinary team in line with locally agreed protocols and supported by The Renal Association's Clinical practice guideline: vascular access for haemodialysis.

Quality measures

Structure
a) Evidence of local arrangements to ensure that adults receiving haemodialysis have their vascular access monitored and maintained using systematic assessment.
Data source: Local data collection.
b) Evidence of a local protocol to ensure that complications of vascular access are recorded and regularly reviewed within the unit.
Data source: Local data collection.
Process
Proportion of adults receiving haemodialysis who have their vascular access monitored and maintained using systematic assessment.
Numerator – the number in the denominator who have a documented plan recording the monitoring and maintenance of their vascular access using systematic assessment.
Denominator – the number of adults receiving haemodialysis.
Data source: Local data collection.
Outcomes
a) Infection rates (by vascular access type: arteriovenous fistula, arteriovenous graft, non‑tunnelled line, tunnelled line).
Data source: Local data collection. The UK Renal Registry details renal centre‑specific infection rates by access type as reported to Public Health England where completion of renal failure and dialysis information is available. See also service audit markers 1–3 for infection episodes in The Renal Association's Clinical practice guideline: vascular access for haemodialysis, recommendation 1.3.
b) Rupture of vascular access (fistula and graft).
Data source: Local data collection. See also service audit marker 4 for infection episodes in The Renal Association's Clinical practice guideline: vascular access for haemodialysis, recommendation 1.3.
c) Catheter patency.
Data source: Local data collection.
d) Interventions needed for non‑functioning or inadequately functioning access.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (specialist renal centres) ensure that systems and local protocols are in place so that adults receiving haemodialysis have their vascular access monitored and maintained using systematic assessment.
Healthcare professionals ensure that adults receiving haemodialysis have their vascular access monitored and maintained using systematic assessment.
Commissioners (NHS England area teams) ensure that service providers monitor and maintain vascular access using systematic assessment in adults receiving haemodialysis.

What the quality statement means for patients, service users and carers

Adults receiving haemodialysis have regular, structured checks of their vascular access (where the dialysis machine is connected to their blood vessels by a needle or tube) to keep it working properly.

Source guidance

Definition of terms used in this quality statement

Systematic assessment
Systematic assessment should be based on The Renal Association's Clinical practice guideline: vascular access for haemodialysis, which highlights the need for appropriate dialysis interventions, systematic observation and advanced surveillance to predict and prevent vascular access failure, and ensuring regular review and audit in line with locally agreed protocols by the multidisciplinary team.
[Adapted from The Renal Association (2011) Clinical practice guideline: vascular access for haemodialysis and expert opinion]

Transplantation – pre-emptive

This quality statement is taken from the renal replacement therapy services quality standard. The quality standard defines clinical best practice in renal replacement therapy services and should be read in full.

Quality statement

Adults who will need renal replacement therapy are offered a pre‑emptive kidney transplant, if they are medically suitable.

Rationale

Evidence shows that transplant outcomes are better for adults who have not been on dialysis (that is, pre‑emptive transplantation) than those who have, and that transplant survival is negatively influenced by the duration of conventional dialysis before transplantation.
It is recommended that adults with progressive deterioration in kidney function for whom transplantation is an option should be placed on the national transplant list within 6 months of their anticipated dialysis start date. Pre‑emptive transplantation should be considered as the treatment of choice for all suitable patients when a living donor is ideally available because this provides most people with the best chance of long‑term rehabilitation.

Quality measures

Structure
a) Evidence of local arrangements to ensure that adults who will need renal replacement therapy have their suitability for kidney transplantation assessed at the earliest opportunity.
Data source: 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.
b) Evidence of local arrangements to ensure that adults who will need renal replacement therapy receive a pre‑emptive kidney transplant, if they are medically suitable.
Data source: 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.
Process
(a) Proportion of adults who will need renal replacement therapy who are assessed for transplant suitability.
Numerator – the number in the denominator who are assessed for transplant suitability.
Denominator – the number of adults who will need renal replacement therapy.
Data source: Local data collection.
(b) Proportion of adults who will need renal replacement therapy and are medically suitable for pre‑emptive kidney transplantation, who receive a pre‑emptive kidney transplant.
Numerator – the number in the denominator receiving a pre‑emptive kidney transplant.
Denominator – the number of adults who will need renal replacement therapy and are medically suitable for pre‑emptive kidney transplantation.
Data source: Local data collection. The Health and Social Care Information Centre Hospital Episode Statistics contains data on kidney transplantation. The Office of population censuses and survey classification of surgical operations and procedures (4th revision) 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 in The Renal Association's Clinical practice guideline: assessment of the potential kidney transplant recipient, audit criterion 4, and Clinical practice guideline: planning, initiating and withdrawal of renal replacement therapy, audit measure 4.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (hospitals and specialist renal centres) work together to ensure that adults who will need renal replacement therapy are offered pre‑emptive kidney transplantation if they are medically suitable.
Healthcare professionals ensure that they assess adults who will need renal replacement therapy for transplant suitability, and offer pre‑emptive kidney transplantation to adults who are medically suitable.
Commissioners (clinical commissioning groups and NHS England area teams) ensure that they work together to commission services for adults who will need renal replacement therapy and are medically suitable for transplantation to receive pre‑emptive kidney transplantation.

What the quality statement means for patients, service users and carers

Adults who have kidney failure are offered a kidney transplant, if it is a suitable treatment for them, before they need to start dialysis. Kidney transplant involves replacing a kidney with one from a person who has recently died or from a relative.

Source guidance

Definitions of terms used in this quality statement

Pre‑emptive transplantation
Pre‑emptive kidney transplantation is carried out for adults who are medically suitable before dialysis is needed. A kidney may be used from a living or dead donor, although a living donor is preferred.
Adults who are medically suitable (for pre‑emptive transplantation)
Medically suitable people should include those whose transplant workup has been delayed by poor access to appropriate investigations such as coronary angiography.

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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: November 2014

© NICE 2014

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