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Chronic kidney disease

About

What is covered

This interactive flowchart 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 interactive flowchart 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 interactive flowchart. 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 interactive flowchart

10 October 2017 Immunosuppressive therapy for kidney transplant in children and young people (NICE technology appraisal guidance 482) and immunosuppressive therapy for kidney transplant in adults (NICE technology appraisal guidance 481) added to transplant.
26 July 2017 Chronic kidney disease in adults (NICE quality standard 5) updated.
27 June 2017 Etelcalcetide for treating secondary hyperparathyroidism (NICE technology appraisal guidance 448) added to dialysis.
20 June 2017 Multiple frequency bioimpedance devices to guide fluid management in people with chronic kidney disease having dialysis (NICE diagnostics guidance 29) added to dialysis.
27 November 2014 Renal replacement therapy services (NICE quality standard 72) added.
22 July 2014 Chronic kidney disease in adults: assessment and management (NICE guideline CG182) added. Structure revised as this guideline replaces NICE guideline CG73.
25 October 2011 Peritoneal dialysis path added.

Person-centred care

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

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on chronic kidney disease (renal failure) in an interactive flowchart

What is covered

This interactive flowchart 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 interactive flowchart 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 interactive flowchart. 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 interactive flowchart

10 October 2017 Immunosuppressive therapy for kidney transplant in children and young people (NICE technology appraisal guidance 482) and immunosuppressive therapy for kidney transplant in adults (NICE technology appraisal guidance 481) added to transplant.
26 July 2017 Chronic kidney disease in adults (NICE quality standard 5) updated.
27 June 2017 Etelcalcetide for treating secondary hyperparathyroidism (NICE technology appraisal guidance 448) added to dialysis.
20 June 2017 Multiple frequency bioimpedance devices to guide fluid management in people with chronic kidney disease having dialysis (NICE diagnostics guidance 29) added to dialysis.
27 November 2014 Renal replacement therapy services (NICE quality standard 72) added.
22 July 2014 Chronic kidney disease in adults: assessment and management (NICE guideline CG182) added. Structure revised as this guideline replaces NICE guideline CG73.
25 October 2011 Peritoneal dialysis path added.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Immunosuppressive therapy for kidney transplant in adults (2017) NICE technology appraisal guidance 481
Etelcalcetide for treating secondary hyperparathyroidism (2017) NICE technology appraisal guidance 448
Laparoscopic insertion of peritoneal dialysis catheter (2007) NICE interventional procedures guidance 208
Laparoscopic live donor simple nephrectomy (2004) NICE interventional procedures guidance 57
Renal replacement therapy services for adults (2014) NICE quality standard 72
Chronic kidney disease in adults (2011 updated 2017) NICE quality standard 5

Quality standards

Chronic kidney disease in adults

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

Quality statements

Transplantation – on dialysis

This quality statement is taken from the renal replacement therapy services for adults quality standard. The quality standard defines clinical best practice in renal replacement therapy services for adults 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: Local data collection. 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: Local data collection. 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: Local data collection. 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.

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 for adults quality standard. The quality standard defines clinical best practice in renal replacement therapy services for adults 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 for adults quality standard. The quality standard defines clinical best practice in renal replacement therapy services for adults 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.

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 for adults quality standard. The quality standard defines clinical best practice in renal replacement therapy services for adults 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.
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. 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 for adults quality standard. The quality standard defines clinical best practice in renal replacement therapy services for adults 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 for adults quality standard. The quality standard defines clinical best practice in renal replacement therapy services for adults 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 for adults quality standard. The quality standard defines clinical best practice in renal replacement therapy services for adults 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 for adults quality standard. The quality standard defines clinical best practice in renal replacement therapy services for adults 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.
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.
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. 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.

Identification and monitoring

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

Quality statement

Adults with, or at risk of, chronic kidney disease (CKD) have eGFRcreatinine and albumin:creatinine ratio (ACR) testing at the frequency agreed with their healthcare professional.

Rationale

Routine monitoring of key markers of kidney function for adults with, or at risk of, CKD will enable earlier diagnosis and early action to reduce the risks of CKD progression, such as cardiovascular disease, end-stage kidney disease and mortality.

Quality measures

Structure
Evidence of local systems that invite adults with, or at risk of, CKD to have eGFRcreatinine and ACR testing.
Data source: Local data collection, for example, through local protocols on appointment reminders.
Process
a) Proportion of adults with CKD who had eGFRcreatinine testing in the past year.
Numerator – the number in the denominator who had eGFRcreatinine testing in the past year.
Denominator – the number of adults with CKD.
Data source: Local data collection, for example, audit of health records. The National CKD Audit reports the percentage of people with coded CKD stages 3 to 5 with a repeat blood test of their kidney function in the past year.
b) Proportion of adults with CKD who had ACR testing at the frequency agreed with their healthcare professional.
Numerator – the number in the denominator who had ACR testing at the frequency agreed with their healthcare professional.
Denominator – the number of adults with CKD.
Data source: Local data collection, for example, audit of health records. The National CKD Audit reports the percentage of people with coded CKD stages 3 to 5 who had an ACR urinary test result in the previous year.
c) Proportion of adults at risk of CKD who had eGFRcreatinine testing at the frequency agreed with their healthcare professional.
Numerator – the number in the denominator who had eGFRcreatinine testing at the frequency agreed with their healthcare professional.
Denominator – the number of adults at risk of CKD.
Data source: Local data collection, for example, audit of health records. The National CKD Audit reports the percentage of people with diabetes tested using serum creatinine in the past year, and people at risk of CKD without diabetes tested in the past 5 years.
d) Proportion of adults at risk of CKD who had ACR testing at the frequency agreed with their healthcare professional.
Numerator – the number in the denominator who had ACR testing at the agreed frequency.
Denominator – the number of adults at risk of CKD.
Data source: Local data collection, for example, audit of health records. The National CKD Audit reports the percentage of people with diabetes tested using ACR in the past year, and people at risk of CKD without diabetes tested in the past 5 years.
Outcomes
a) Prevalence of undiagnosed CKD.
Data source: NHS Digital’s Quality and Outcomes Framework 2015–16 reports the prevalence of patients aged 18 or over with CKD with classification of categories G3a to G5 registered at GP practices. Comparing recorded prevalence with expected prevalence estimated using a tool, such as Public Health England’s CKD prevalence model, can give an indication of local prevalence of undiagnosed CKD.
b) Stage of CKD at diagnosis.
Data source: Local data collection, for example, audit of health records.

What the quality statement means for different audience

Service providers (general practices and secondary care services, such as renal, cardiology, diabetes and rheumatology clinics) ensure that systems are in place to identify adults with, or at risk of, CKD, for example through computerised or manual searching of medical records, and offer an appointment to discuss with them how frequently they should have eGFRcreatinine and ACR testing. They also have systems in place to offer appointments for testing at the agreed frequency.
Healthcare professionals (GPs, nephrologists, cardiologists, diabetologists, rheumatologists, nurses and pharmacists) discuss and agree the frequency of eGFRcreatinine and ACR testing with adults who have, or at risk of, CKD and offer testing at the agreed frequency. They can then agree any appropriate treatment based on the results of testing.
Commissioners (clinical commissioning groups and NHS England) ensure that they commission services in which adults with, or at risk of, CKD have eGFRcreatinine and ACR testing at the frequency agreed with their healthcare professional. They might do this by checking that services have systems in place to identify adults with, or at risk of, CKD and offer appointments to discuss and agree the frequency of eGFRcreatinine and ACR testing.
Adults who have, or may be at risk of, CKD discuss and agree with their healthcare professional how often they should have tests to check how well their kidneys are working. They are offered blood and urine tests at the agreed frequency to find out if their CKD is worsening (progressing), or if they have kidney problems. The blood test is at least once a year for adults with CKD. People with CKD are offered information and education relevant to the cause of kidney disease, how advanced it is, any complications they may have and the chances of it getting worse, to help fully understand and make informed choices about treatment. They are also be able to get psychological support if needed – for example, support groups, counselling or support from a specialist nurse.

Source guidance

Chronic kidney disease in adults: assessment and management (2014) NICE guideline CG182, recommendations 1.1.27, 1.1.28 (key priority for implementation), 1.3.1 and 1.3.2 (key priority for implementation).

Definitions of terms used in this quality statement

Adults with CKD
CKD is defined as abnormalities of kidney function or structure present for more than 3 months, with implications for health. This includes:
  • people with markers of kidney damage, including 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 or a history of kidney transplantation
  • people with a glomerular filtration rate (GFR) 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).
(NICE’s guideline on chronic kidney disease in adults)
Adults at risk of CKD
Adults with any of the following risk factors:
  • diabetes
  • hypertension
  • acute kidney injury
  • cardiovascular disease (ischaemic heart disease, chronic heart failure, peripheral vascular disease or 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 – for example, autosomal dominant polycystic kidney disease
  • opportunistic detection of haematuria
  • prescribed drugs that have an impact on kidney function, such as calcineurin inhibitors (for example, cyclosporin or tacrolimus), lithium and non-steroidal anti-inflammatory drugs (NSAIDs).
(NICE’s guideline on chronic kidney disease in adults, recommendations 1.1.27 and 1.1.28 and expert opinion)
eGFRcreatinine testing
A blood test that estimates glomerular filtration rate (GFR) by measuring serum creatinine. It is used as an estimate of kidney function to identify kidney disease and monitor CKD progression. Clinical laboratories should use the Chronic Kidney Disease Epidemiology Collaboration (CKD‑EPI) creatinine equation to estimate GFRcreatinine, using creatinine assays with calibration traceable to standardised reference material.
(Adapted from NICE’s guideline on chronic kidney disease in adults, recommendation 1.1.2)
Albumin:creatinine ratio (ACR) testing
A test used to detect and identify protein in the urine, which is a sign of kidney disease, and can be used to assess progression of CKD.
(Adapted from NICE’s guideline on chronic kidney disease in adults, recommendation 1.1.18 and full guideline)
At the frequency agreed with their healthcare professional
The frequency of monitoring should be discussed and agreed by the person and their healthcare professional. Table 2 in NICE’s guideline on chronic kidney disease in adults should be used to guide the frequency of GFR monitoring. Adults with CKD should be seen at least annually and adults at risk of CKD can be seen annually or less often for monitoring of eGFR. ACR does not need to be measured every time eGFR is measured, except when evaluating response to a treatment targeted at reducing proteinuria. Frequency of monitoring is determined by the stability of kidney function and the ACR level, and tailored to the individual according to:
  • the underlying cause of CKD
  • past patterns of eGFR and ACR (but be aware that CKD progression is often non-linear)
  • comorbidities, especially heart failure
  • changes to their treatment (such as renin–angiotensin–aldosterone system [RAAS] antagonists, NSAIDs and diuretics)
  • intercurrent illness
  • whether they have chosen conservative management of CKD.
(Adapted from NICE’s guideline on chronic kidney disease in adults, recommendations 1.3.1 and 1.3.2 and full guideline)

Blood pressure control

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

Quality statement

Adults with chronic kidney disease (CKD) have their blood pressure maintained within the recommended range.

Rationale

People with CKD are at a higher risk of high blood pressure. Maintaining blood pressure within a target range reduces the risk of cardiovascular disease, CKD progression and mortality.

Quality measures

Structure
a) Evidence of local systems to identify and invite adults with CKD to have a blood pressure reading.
Data source: Local data collection, for example, through local protocols on appointment reminders.
b) Evidence of the availability of equipment to take a blood pressure reading from adults with CKD.
Data source: Local data collection, for example, service specifications.
Process
a) Proportion of adults with CKD without diabetes and with an ACR below 70 mg/mmol whose systolic blood pressure is between 120–139 mmHg and their diastolic blood pressure below 90 mmHg.
Numerator – the number in the denominator whose systolic blood pressure is between 120–139 mmHg and their diastolic blood pressure below 90 mmHg.
Denominator – the number of adults with CKD without diabetes and with an ACR below 70 mg/mmol.
Data source: Local data collection, for example, audit of health records. The National CKD Audit reports the percentage of people with coded CKD stages 3 to 5 with blood pressures below the recommended targets.
b) Proportion of adults with CKD and diabetes whose systolic blood pressure is between 120–129 mmHg and their diastolic blood pressure below 80 mmHg.
Numerator – the number in the denominator whose systolic blood pressure is between 120–129 mmHg and their diastolic blood pressure below 80 mmHg.
Denominator – the number of adults with CKD and diabetes.
Data source: Local data collection, for example, audit of health records. The National CKD Audit reports the percentage of people with coded CKD stages 3 to 5 with blood pressures below the recommended targets.
c) Proportion of adults with CKD and an ACR of 70 mg/mmol or more whose systolic blood pressure is between 120–129 mmHg and their diastolic blood pressure below 80 mmHg.
Numerator – the number in the denominator whose systolic blood pressure is between 120–129 mmHg and their diastolic blood pressure below 80 mmHg.
Denominator – the number of adults with CKD and an ACR of 70 mg/mmol or more.
Data source: Local data collection, for example, audit of health records. The National CKD Audit reports the percentage of people with coded CKD stages 3 to 5 with blood pressures below the recommended targets.

Outcomes

a) Prevalence of cardiovascular disease among people with CKD.
Data source: Local data collection, for example, audit of health records. The UK Renal Registry collects data on comorbidities of renal patients, including angina, heart failure and atrial fibrillation.
b) Incidence of cardiovascular events for people with CKD.
Data source: Local data collection, for example, audit of health records. The UK Renal Registry collects data on comorbidities of renal patients, including dates of heart failure, transient ischaemic attack, stroke and ST segment elevation myocardial infarction (STEMI).
c) Cardiovascular mortality rates among people with CKD.
Data source: Local data collection, for example, audit of health records. The UK Renal Registry collects data on the cause of death of renal patients.
d) Incidence of end-stage kidney disease.
Data source: Local data collection, for example, audit of health records. The UK Renal Registry collects data on the first date of renal replacement therapy or start of CKD stage 5 in renal patients.

What the quality statement means for different audiences

Service providers (general practices and secondary care services) ensure that systems are in place for adults with CKD to have their blood pressure maintained within the recommended range. This might involve having the equipment to take a blood pressure reading, using clinical IT systems to compare patients to the recommended range when entering a blood pressure reading, or flagging when patients need a blood pressure reading.
Healthcare professionals (GPs, nephrologists, nurses and pharmacists) monitor the blood pressure of adults with CKD and are aware of the recommended ranges. They support people to keep their blood pressure within the recommended range, for example, by starting or adjusting treatment, or advising on lifestyle changes.
Commissioners (clinical commissioning groups and NHS England) ensure that they commission services in which adults with CKD have their blood pressure maintained within the recommended range. They work with service providers to ensure that adults with CKD are identified, and have a blood pressure reading and any necessary support to maintain it within the recommended range.
Adults with CKD are supported to keep their blood pressure at a healthy level. If it is too high, their healthcare professional might offer medicine, or change the medicine they are taking, or suggest lifestyle changes, to help to control it.

Source guidance

Chronic kidney disease in adults: assessment and management (2014) NICE guideline CG182, recommendations 1.6.1 and 1.6.2.

Definitions of terms used in this quality statement

Adults with CKD
CKD is defined as abnormalities of kidney function or structure present for more than 3 months, with implications for health. This includes:
  • people with markers of kidney damage, including 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 or a history of kidney transplantation
  • people with a glomerular filtration rate (GFR) 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).
(NICE’s guideline on chronic kidney disease in adults)
Recommended range
Blood pressure should be monitored and maintained within the following ranges:
  • In people with CKD aim to keep the systolic blood pressure below 140 mmHg (target range 120–139 mmHg) and the diastolic blood pressure below 90 mmHg.
  • 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.
[Adapted from NICE’s guideline on chronic kidney disease in adults, recommendations 1.6.1 and 1.6.2]
.

Statins for people with CKD

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

Quality statement

Adults with chronic kidney disease (CKD) are offered atorvastatin 20 mg

Rationale

There is a higher risk of cardiovascular disease (CVD) in people with CKD. After discussing the risks and benefits of starting statin therapy with a healthcare professional, adults with CKD may choose statin therapy as an appropriate treatment to reduce their risk of first CVD events, or of future CVD events in adults who have already had an event, such as a heart attack or stroke. Statins are a clinically effective treatment for preventing CVD, and reducing the risks associated with CVD, for people who have CKD. Atorvastatin 20 mg is recommended as the preferred initial high-intensity statin because it is clinically and cost effective for the primary and secondary prevention of CVD.

Quality measures

Structure
a) Evidence of the availability of atorvastatin 20 mg within local service providers.
Data source: Local data collection, for example, local formularies.
b) Evidence of local systems to check whether adults with CKD are taking atorvastatin 20 mg and invite them to discuss starting treatment if not.
Data source: Local data collection, for example, service specifications.
Process
Proportion of adults with CKD who receive atorvastatin 20 mg.
Numerator – the number in the denominator who receive atorvastatin 20 mg.
Denominator – the number of adults with CKD.
Data source: Local data collection, for example, audit of health records. The National CKD Audit reports the percentage of people with coded CKD stages 3 to 5 who are on a statin.

Outcomes

a) Prevalence of cardiovascular disease among people with CKD.
Data source: Local data collection, for example, audit of health records. The UK Renal Registry collects data on comorbidities of renal patients, including angina, heart failure and atrial fibrillation.
b) Incidence of cardiovascular events for people with CKD.
Data source: Local data collection, for example, audit of health records. The UK Renal Registry collects data on comorbidities of renal patients, including dates of heart failure, transient ischaemic attack, stroke and ST segment elevation myocardial infarction (STEMI).
c) Cardiovascular mortality rates among people with CKD.
Data source: Local data collection, for example, audit of health records. The UK Renal Registry collects data on the cause of death of renal patients.
d) Proportion of people with CKD with a greater than 40% reduction in non‑high‑density lipoprotein cholesterol.
Data source: Local data collection, for example, audit of health records.

What the quality statement means for different audiences

Service providers (general practices and secondary care services, such as renal, cardiology, diabetes and rheumatology clinics) ensure that systems are in place for adults with CKD to be offered atorvastatin 20 mg. For example, this may be done through incorporating treatment algorithms into software applications to provide users with patient-specific recommendations on treatment.
Health professionals (GPs, nephrologists, cardiologists, diabetologists, rheumatologists, nurses and pharmacists) check whether adults with CKD are taking a statin, and discuss the risks and benefits of starting statin therapy if not. They offer atorvastatin 20 mg and increase the dose if an adequate response to treatment is not achieved and eGFR is 30 ml/min/1.73 m2 or more. If a person is not able to tolerate atorvastatin 20 mg or reports adverse effects, they discuss alternative options such as stopping the statin or changing the dose or type of statin.
Commissioners (clinical commissioning groups and NHS England) ensure that they commission services in which adults with CKD are offered atorvastatin 20 mg. Commissioners may do this by seeking evidence of practice through clinical audits.
Adults with CKD are at a higher risk of heart attacks and strokes. To help reduce the risk they are offered a type of medicine called a statin, which lowers the level of cholesterol (sometimes called lipids) in the blood. If their cholesterol level does not decrease enough, they may change to a higher dose. If the statin causes any side effects, their doctor might ask them to stop taking it for a while to check that they are caused by the statin. Their doctor might discuss reducing the dose or changing to a different statin.

Source guidance

Definitions of terms used in this quality statement

Adults with CKD
CKD is defined as abnormalities of kidney function or structure present for more than 3 months, with implications for health. This includes:
  • people with markers of kidney damage, including 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 or a history of kidney transplantation
  • people with a glomerular filtration rate (GFR) 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).
(NICE’s guideline on chronic kidney disease in adults)

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

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

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

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: October 2017

© NICE 2017. All rights reserved. Subject to Notice of rights.

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