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Chronic kidney disease

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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

2 October 2018 Recommendations on renal replacement therapy updated on publication of renal replacement therapy and conservative management (NICE guideline NG107).
24 April 2018 Robot-assisted kidney transplant (NICE interventional procedures guidance 609) added to transplantation.
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 transplantation.
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 secondary hyperparathyroidism.
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 diet and fluids.
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.

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

2 October 2018 Recommendations on renal replacement therapy updated on publication of renal replacement therapy and conservative management (NICE guideline NG107).
24 April 2018 Robot-assisted kidney transplant (NICE interventional procedures guidance 609) added to transplantation.
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 transplantation.
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 secondary hyperparathyroidism.
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 diet and fluids.
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.

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
Robot-assisted kidney transplant (2018) NICE interventional procedures guidance 609
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 updated 2018) 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.
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.
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.
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: NHS Digital’s Hospital Episode Statistics contains data on kidney transplantation.

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

Renal replacement therapy and conservative management (2018) NICE guideline NG107, recommendations 1.3.3, 1.3.4, 1.3.5 and 1.3.6

Dialysis access preparation

This statement has been removed. For more details see update information in the NICE guideline.

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

When dialysis is needed long-term it is important to offer home-based dialysis. People should be supported to consider the pros and cons of different treatment options and the potential impact on their lifestyle so that they can make an informed choice.

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 have a recorded discussion about the option of home-based dialysis.
Numerator – the number in the denominator who have a recorded discussion about the option of home-based dialysis.
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 offer home-based dialysis to adults on long-term dialysis.
Healthcare professionals ensure that they review people on long-term dialysis, offer them home-based dialysis and provide support to help them make an informed decision.
Commissioners (NHS England area teams) ensure that they commission services that offer adults on long-term dialysis the opportunity to choose home-based dialysis.

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. They should be supported to consider the pros and cons before they make a decision.

Source guidance

Renal replacement therapy and conservative management (2018) NICE guideline NG107, recommendation 1.3.8

Patient transport

This statement has been removed. For more details see update information in the NICE guideline.

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.
Process
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’s clinical practice guideline on 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 on 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.
b) Rupture of vascular access (fistula and graft).
Data source: Local data collection.
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

The Renal Association (2015) Clinical practice guideline: vascular access for haemodialysis, recommendations 6.3 and 6.5

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’s clinical practice guideline on 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. NHS Digital’s Hospital Episode Statistics contains data on kidney transplantation. Also contained in The Renal Association’s clinical practice guideline on 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

Renal replacement therapy and conservative management (2018) NICE guideline NG107, recommendation 1.3.6

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 deceased donor, although a living donor is preferred.
[Adapted from NICE’s guideline on renal replacement therapy and conservative management]

Equality and diversity considerations

People with a BMI greater than 30 should not be excluded from transplantation based on BMI alone.

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

Rationale and impact: coordinating and delivering care

Rationale

The committee noted that people on RRT experience considerable treatment burden and that strategies should be adopted to reduce this. There was no evidence on care coordination by a keyworker so the committee recommended the healthcare professional responsible for renal care as a first point of contact. They made a research recommendation on care coordination by a keyworker to inform future guidance.

Impact

The recommendation on reducing treatment burden standardises and reinforces good practice. Some healthcare professionals may need to change their practice but this would not result in a substantial resource impact.
For more information, see evidence review M: coordinating care.

When to refer

Take into account the individual's wishes and comorbidities when considering referral.
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 the NICE recommendations on hypertension)
  • known or suspected rare or genetic causes of CKD
  • suspected renal artery stenosis.
People with CKD and renal outflow obstruction should normally be referred to urological services, unless urgent medical intervention is required – for example, for the treatment of hyperkalaemia, severe uraemia, acidosis or fluid overload.
Consider discussing management issues with a specialist by letter, email or telephone in cases where it may not be necessary for the person with CKD to be seen by the specialist.
Once a referral has been made and a plan jointly agreed (between the person with CKD or their carer and the healthcare professional), it may be possible for routine follow-up to take place at the patient's GP surgery rather than in a specialist clinic. If this is the case, criteria for future referral or re-referral should be specified.

Rationale and impact: providing contact details

Rationale

There was limited evidence on the coordination of care but the committee agreed that people should know who to contact with questions about their condition or treatment. This is particularly important when they start or change RRT modalities.

Impact

Current practice is variable in terms of when a person is given the details of the person responsible for care. This recommendation will ensure that this is done before starting treatment or when switching modalities or to conservative management.
For more information, see evidence review M: coordinating care.

Rationale and impact: providing information and support

Rationale

The committee used the evidence and their own experience to update the recommendations on information and support from NICE's 2011 guideline on peritoneal dialysis (CG125) and to extend these to cover other forms of RRT and conservative management. Key findings related to information being provided well in advance of decisions being needed, multiple formats of information being available, and full information on all modalities being provided. Information should also be provided on the psychological impact of starting RRT and the decision-making process.

Impact

The recommendations broadly reflect current practice and therefore are unlikely to have a resource impact. They focus mainly on the principles of information and support rather than on specific interventions.

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

Rationale and impact: when to assess

Rationale

Some evidence indicated that earlier referral to nephrology services improved survival on RRT at 90 days. The committee were interested in the timing of referral for assessment for RRT and used their experience to recommend that this should be at least 1 year before RRT is likely to be needed. They agreed that this would provide time for clinical and psychological preparation for dialysis or pre-emptive transplantation, and give the person, family members and carers enough time to think about the options. The committee acknowledged that there might be possible harms and costs for people who were referred but did not go on to need RRT, but they agreed that these were outweighed by the benefits of early referral for most people.

Impact

The recommendation generally reflects current practice so there should be no significant change in practice or substantial resource impact to the NHS in England.

Possible symptoms in people on renal replacement therapy or conservative management

Category
Symptom
General
Breathlessness
Fatigue
Insomnia
Itching
Lethargy
Pain
Poor appetite
Swelling
Taste changes
Thirst
Weakness
Weight loss/gain
Gastro-intestinal/urological
Abdominal cramps
Change in bowel or urinary habits
Nausea
Musculoskeletal
Muscle cramps
Restless legs
Neurological
Cognitive impairment
Dizziness
Headaches
Psychological/behavioural
Anxiety
Body image concerns
Depression
Mood disturbances/fluctuations
Sexual dysfunction

Rationale and impact: assessing the condition

Rationale

The committee recognised that an assessment should involve preparing people for RRT, for example, by explaining the procedures to create vascular access and checking heart function and immunity. Psychosocial preparation is also important for reducing non-adherence and improving outcomes. They also highlighted the importance of discussing a person's preferences and understanding how decisions on RRT or conservative management are likely to affect a person's everyday life.
No evidence was identified on the psychological assessment of transplant recipients or donors. The committee agreed that there were likely benefits for identifying risk factors for non-adherence or morbidity after the operation. These could include substance misuse, current non-adherence or a previous or current mental health condition. Given the lack of evidence and potential resource impact, the committee agreed that assessment could be considered for specific high-risk groups.
There was no evidence on cardiac assessment before transplantation. The committee discussed current practice and agreed it is very variable. They therefore decided to make a research recommendation to inform future practice.

Impact

Psychological assessment in people at high risk of non-adherence or morbidity is current practice in many areas. The recommendation is likely to lead to better targeting of psychological assessment in other areas. The recommendation was not considered likely to have a substantial resource impact overall.

Rationale and impact: joint decisions about treatment options

Rationale

People who are likely to need RRT should be supported to make decisions about treatment options, including conservative management. There was no evidence of differential benefits or harms in any specific group of people and the committee agreed that the decision needs to be based on individual factors (such as frailty, cognitive impairment and multimorbidity) and patient preference.

Impact

Currently there is a mix of HDF and HD provision in the NHS in England. The recommendation to consider HDF over HD for in-centre dialysis may affect resource use in areas where this is a change in practice. There are likely to be additional costs relating to consumables and water consumption with HDF compared with HD, but these may be partly offset by reduced use of erythropoietin-stimulating agent. There may be additional costs for machines where HDF-capable machines are not currently used. However, most centres already have some HDF-capable machines. This will enable them to accommodate any initial increased demand for HDF. Provision can be expanded if demand increases within the usual replacement cycles. These additional costs may result in a substantial resource impact to the NHS in England overall. However, this is uncertain as it is not possible to accurately predict how widely additional use of HDF will be considered.
Although use of different RRT modalities and conservative management varies between areas, other recommendations reinforce current good practice to offer people a choice of modalities and settings, and conservative management, and so are not expected to have a substantial resource impact.
The committee agreed that people are often not offered regular opportunities to discuss the option of switching treatment modality or stopping RRT and so this may be a change in practice in many areas. However, these discussions could form part of current patient reviews and so would not mean a difference in resource use. More regular discussions may lead to more people switching or stopping RRT but this is not expected to result in a substantial resource impact overall.

Information about treatments and how they may affect lifestyle

Information about treatments*
Information about how treatments may affect lifestyle
  • What they involve, for example, availability of assistance, time that treatment takes place, and number of sessions per day/week
  • Potential benefits
  • The benefits of adherence to treatment regimens and the potential consequences of non-adherence
  • Potential adverse effects, their severity and how they may be managed
  • The likely prognosis on dialysis, after transplant or with conservative management
  • The transplant listing process (when appropriate)
  • Switching the modality of RRT and the possible consequences (that is, the impact on the person's life or how this may affect future treatment or outcomes)
  • Reviewing treatment decisions
  • Stopping treatment and planning end of life care
  • The person or carer's ability to carry out and adjust the treatment themselves
  • The possible impact of dietary management and management of fluid allowance
  • How treatment may fit in with daily activities such as work, school, hobbies, family commitments and travel for work or leisure
  • How treatment may affect sexual function, fertility and family planning
  • Opportunities to maintain social interaction
  • How treatment may affect body image
  • How treatment may affect physical activity (for example, whether contact sports should be avoided after transplantation, whether swimming should be avoided with peritoneal dialysis)
  • Whether a person's home will need to be modified to accommodate treatment
  • How much time and travel treatment or training will involve
  • The availability of transport
  • The flexibility of the treatment regimen
  • Whether any additional support or services might be needed
*Treatments include RRT, conservative management and dietary intervention.

Rationale and impact: transplantation

Rationale

Evidence showed that if RRT is chosen, transplantation offers a clear advantage over dialysis in terms of extending life. This benefit was observed in each age group. In the committee's experience, quality of life and hospitalisation are also likely to be improved by transplantation. However, the individual factors that affect the risks and benefits of transplantation, for example, comorbidities, should be discussed. There was no evidence on cost effectiveness but the committee considered transplantation likely to have a lower cost over the long term due to the cost of avoiding dialysis. The committee agreed to recommend pre-emptive transplantation with a living donor or, if this is not an option, a transplant from a deceased donor.
The committee noted that the only available evidence suggested that people with a BMI greater than 30 benefited from transplant (as opposed to dialysis) to a similar degree as people with a BMI of 30 or under, in terms of mortality. The committee agreed to recommend that healthcare professionals do not exclude people from transplantation based on BMI alone.

Impact

Currently there is a mix of HDF and HD provision in the NHS in England. The recommendation to consider HDF over HD for in-centre dialysis may affect resource use in areas where this is a change in practice. There are likely to be additional costs relating to consumables and water consumption with HDF compared with HD, but these may be partly offset by reduced use of erythropoietin-stimulating agent. There may be additional costs for machines where HDF-capable machines are not currently used. However, most centres already have some HDF-capable machines. This will enable them to accommodate any initial increased demand for HDF. Provision can be expanded if demand increases within the usual replacement cycles. These additional costs may result in a substantial resource impact to the NHS in England overall. However, this is uncertain as it is not possible to accurately predict how widely additional use of HDF will be considered.
Although use of different RRT modalities and conservative management varies between areas, other recommendations reinforce current good practice to offer people a choice of modalities and settings, and conservative management, and so are not expected to have a substantial resource impact.
The committee agreed that people are often not offered regular opportunities to discuss the option of switching treatment modality or stopping RRT and so this may be a change in practice in many areas. However, these discussions could form part of current patient reviews and so would not mean a difference in resource use. More regular discussions may lead to more people switching or stopping RRT but this is not expected to result in a substantial resource impact overall.

Rationale and impact: dialysis options

Rationale

Choice of dialysis modalities
Limited evidence showed that if a transplant is not possible, peritoneal dialysis and HD offered similar benefits and equivalent harms. There was uncertainty about the differences in costs between peritoneal dialysis and HD due to uncertainty in current UK dialysis costs and transport costs. There was no evidence comparing HDF and peritoneal dialysis. The committee agreed that peritoneal dialysis and HD/HDF may have quite different effects on a person's life (for example, affecting their ability to travel and the need for self-care) so they agreed that a person should be able to choose the type of dialysis most suitable for them. Peritoneal dialysis should be considered for children under 2 years due to difficulties with vascular access and extracorporeal blood volume.
There was no evidence to suggest clear differences between home and in-centre (hospital or satellite unit) HD/HDF. There is uncertainty in current UK dialysis costs but they may be lower at home. The committee acknowledged that these treatments can have very different effects on lifestyle and recommended patient choice.
Evidence suggested that in-centre HDF was more effective than in-centre HD and was cost effective so the committee agreed that HDF rather than HD should be recommended when dialysis was in centre. However, they were aware of an ongoing trial H4RT comparing high-volume HDF with high-flux HD and, following stakeholder consultation, changed the recommendation to consider HDF rather than HD for in-centre dialysis. The committee noted that HD may be done more frequently at home than in centre. The benefits of HDF are unknown in people who dialyse more frequently. There was no evidence on the efficacy of HDF at home. The committee was aware that some centres offer home HDF, although some people opt for transportable dialysis machines (which cannot do HDF currently) and these centres also provide home HD. Taking all of this information together the committee could not recommend one option over another for HD/HDF at home. They decided that either HD or HDF could be considered.
There was no evidence comparing HD/HDF and peritoneal dialysis as initial therapy for people who start dialysis in an unplanned way. The committee agreed to make a research recommendation on this to inform future guidance.
There was no evidence to suggest clear differences between APD and CAPD. Again the committee acknowledged that these treatments can have very different effects on lifestyle and recommended patient choice.
The committee agreed that people should have regular opportunities to review treatment options.
Sequencing
There was not enough evidence to recommend any particular sequence of RRT modalities. The committee agreed that decisions about sequence would mostly be guided by personal circumstances.

Impact

Currently there is a mix of HDF and HD provision in the NHS in England. The recommendation to consider HDF over HD for in-centre dialysis may affect resource use in areas where this is a change in practice. There are likely to be additional costs relating to consumables and water consumption with HDF compared with HD, but these may be partly offset by reduced use of erythropoietin-stimulating agent. There may be additional costs for machines where HDF-capable machines are not currently used. However, most centres already have some HDF-capable machines. This will enable them to accommodate any initial increased demand for HDF. Provision can be expanded if demand increases within the usual replacement cycles. These additional costs may result in a substantial resource impact to the NHS in England overall. However, this is uncertain as it is not possible to accurately predict how widely additional use of HDF will be considered.
Although use of different RRT modalities and conservative management varies between areas, other recommendations reinforce current good practice to offer people a choice of modalities and settings, and conservative management, and so are not expected to have a substantial resource impact.
The committee agreed that people are often not offered regular opportunities to discuss the option of switching treatment modality or stopping RRT and so this may be a change in practice in many areas. However, these discussions could form part of current patient reviews and so would not mean a difference in resource use. More regular discussions may lead to more people switching or stopping RRT but this is not expected to result in a substantial resource impact overall.

Rationale and impact: planning treatment

Rationale

The committee highlighted the importance of discussing with the person the different types of dialysis and their access and the impacts of these on everyday life.
Evidence suggested that the best time for creating access for peritoneal dialysis by open surgery is around 2 weeks before starting dialysis. There was no evidence on the best time for creating other types of peritoneal access so the committee decided to make a research recommendation to inform future guidance.
Evidence suggested that the best time for creating an AVF for vascular access was 3 to 6 months before starting HD or HDF. It suggested that earlier AVF creation may increase the rate of AVF success. The committee agreed that doing this early (around 6 months) reduced the need for additional access procedures. However, when a fistula is created early, some people may never need it, for example, because they have a pre-emptive transplant. The committee agreed that the benefits of establishing a fistula around 6 months before starting dialysis, including the cost savings associated with avoiding additional access procedures, were likely to outweigh the potential disadvantages and increased costs associated with unused fistulae. The committee noted that the precise timing will vary from person to person, depending on the likely success of fistula creation.
Evidence showed a benefit of routine ultrasound scanning in terms of reduced failure of AVF. Cost calculations based on the clinical evidence suggested that routine scanning is likely to reduce overall costs because of fewer repeat interventions. The committee agreed to recommend routine ultrasound scanning to determine vascular access sites.
The committee noted that there was no evidence to guide the optimum timing of transplant listing and therefore made a research recommendation in this area.

Impact

Current practice for creating vascular access is variable. A minimum timing from creation to use of 6 weeks has been suggested – however, the committee agreed that creation around 6 months reflected common practice. The recommendation is not expected to have a significant impact on practice, but should standardise some current variability. It is not expected to have a substantial resource impact to the NHS in England.
Current practice for creating peritoneal dialysis access via open surgery is broadly in line with the recommendation (that is, 2 weeks before use) and so this recommendation is not expected to have a substantial resource impact to the NHS in England.
Current practice regarding ultrasound scanning to determine access sites is variable; some centres use routine ultrasound scanning but others offer a more selective approach. The recommendation would not involve a large change in practice and is likely to be cost saving because of the reduced need for repeat intervention. It is not expected to have a substantial resource impact to the NHS in England.

Rationale and impact: when to start treatment

Rationale

The committee agreed that when to start dialysis is a complex decision that should take into account a number of factors (symptoms, patient preference, biochemistry, fluid overload and eGFR). Most people start dialysis due to symptoms, but evidence suggested that there was no overall harm or benefit of starting dialysis at an eGFR of around 5 to 7 ml/min/1.73 m2 in the absence of symptoms. However, there was evidence that starting dialysis when there are symptoms or the eGFR reaches 5 to 7 ml/min per 1.73 m2 was cost saving compared with an earlier start. The committee noted that some people prefer to have an agreed starting point (eGFR), but may need dialysis before this because symptoms are affecting normal daily activities. Some people with slowly progressing chronic kidney disease may not recognise and report symptoms that indicate dialysis is needed. Taking all this information together, the committee acknowledged several indications for starting dialysis and agreed that these should be considered on an individual basis.
The committee agreed that it is important to establish whether the symptoms (for example, fatigue and depression) are due to uraemia or not, and to discuss their impact on daily life.
Evidence on the timing of pre-emptive transplant was limited and contradictory, with one study showing a clinically important benefit of transplanting at an eGFR of less than 10 ml/min/1.73 m2 but another showing no difference. The committee agreed to make a research recommendation on this to guide future practice.

Impact

The recommendations reflect common practice for adults and children, and so are not likely to involve a change of practice for most NHS providers or have a substantial resource impact for the NHS in England. If providers need to change from an earlier to a later initiation strategy, this is likely to be cost saving due to a reduction in time on dialysis.

Rationale and impact: diet and fluids

Rationale

Limited evidence, including in people with a transplant, indicated that people receiving RRT or conservative management may benefit from dietary and/or fluid management. The committee agreed that current practice is for people receiving dialysis or conservative management to have an assessment by a specialist dietitian. NICE's guideline on managing hyperphosphataemia in chronic kidney disease recommends assessment by a specialist renal dietitian for those at risk of hyperphosphataemia, which would include these groups of people. They also considered it current practice for dietary advice to be given after transplantation, although this advice is not always given by a specialist renal dietitian. The committee noted that there is some variation in how long people have to wait for this assessment, and variation in ongoing management. The committee agreed that dietary advice is important for people with a transplant, particularly straight after the surgery. This was supported by the evidence. The committee noted the importance of the person giving dietary advice having specialist knowledge of dietary requirements in transplant patients. However, the evidence was too limited to recommend that dietary advice should routinely be from a specialist renal dietitian for this group given it would be a change in practice in many areas and could result in a substantial resource impact.
The committee agreed that following initial assessment further dietary assessment would be determined by specific circumstances or indicators and made a recommendation summarising what these would be. They highlighted that there is variation in the level of dietitian input available in renal centres, which may affect how quickly people can access services or the level of input following initial assessment. However, the evidence was not considered sufficient to make specific recommendations to address this.
The committee agreed that involving family members and carers in discussions was important for improving adherence to dietary management and fluid allowance. There was no evidence on the benefits or harms of a low protein diet so the committee was not able to make a recommendation on this. The committee agreed that dietary management and fluid assessment should not be a 'one-step' process and that people's needs should be reviewed when circumstances change (for example, when switching RRT modalities) or when biochemical measures indicate.

Impact

The recommendations made reflect current practice and are not expected to result in a substantial resource impact to the NHS in England.

Rationale and impact: managing symptoms

Rationale

Evidence identified symptoms that people approaching the need for RRT or receiving RRT or conservative management frequently report as affecting their lives. The committee also identified others (for example, change in urinary habits). People may feel uncomfortable talking about some symptoms (for example, sexual dysfunction) and may not associate them with their condition or its treatment. The committee agreed that healthcare professionals should ask people about symptoms and determine the likely cause. It is important that people understand which symptoms they may experience, which may need further management and if treatment will control them.

Impact

Currently, not all healthcare professionals ask people about all of the symptoms they are experiencing. They may only ask about specific symptoms and not explore all of them. Healthcare professionals should ascertain whether symptoms are due to the person's renal condition or not and explain this to them. This may be a change in practice for some but is not expected to have a substantial resource impact to the NHS in England.
For more information see evidence review H: symptom recognition.

Rationale and impact: switching or stopping treatment

Rationale

There was no evidence on indications for switching treatment and the committee agreed to make research recommendations on possible indicators to inform future guidance. There was no evidence that people on peritoneal dialysis should switch modality in anticipation of future complications such as encapsulating peritoneal sclerosis and the committee agreed this should not be routine. They highlighted that healthcare professionals should monitor for risk factors predicting complications (for example, loss of ultrafiltration).
There was also no evidence to support a switch from peritoneal dialysis to HD/HDF for women who become or wish to become pregnant. The committee agreed that the need for a switch would depend on the adequacy of dialysis, the health of the foetus and the control of urea. They recommended that specialist advice should be sought before any decisions were made.

Impact

The recommendations broadly reflect current good practice and are not expected to have a resource impact to the NHS in England.

Glossary

albumin:creatinine ratio
assisted automated peritoneal dialysis
automated peritoneal dialysis
arteriovenous fistula
body composition monitor
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
haemodiafiltration
haemodialysis
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)
renal replacement therapy

Paths in this pathway

Pathway created: May 2011 Last updated: October 2018

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