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Diagnosing and managing hyperphosphataemia in children and young people

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Chronic kidney disease

About

What is covered

This NICE Pathway covers the early identification and management of chronic kidney disease in adults, children and young people. It includes recommendations on managing anaemia associated with chronic kidney disease and hyperphosphataemia in people with chronic kidney disease.
NICE has produced a COVID-19 rapid guideline on chronic kidney disease. It recommends changes to usual practice to maximise the safety of patients and protect staff from infection during the COVID-19 pandemic.

Updates

Updates to this NICE Pathway

27 October 2021 Percutaneous endovascular forearm arteriovenous fistula creation for haemodialysis access (NICE interventional procedures guidance 710) added to planning treatment.
25 August 2021 Chronic kidney disease (NICE guideline 203) added. Structure revised as this guideline replaces NICE guidelines CG182, CG157 and NG8.
5 August 2020 Electrical stimulation to improve muscle strength in chronic respiratory conditions, chronic heart failure and chronic kidney disease (NICE interventional procedures guidance 677) added to managing symptoms.
12 February 2020 Patiromer for treating hyperkalaemia (NICE technology appraisal guidance 623) added to hyperkalaemia.
3 September 2019 Sodium zirconium cyclosilicate for treating hyperkalaemia (NICE technology appraisal guidance 599) added to hyperkalaemia.
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 in children, young people and adults in an interactive flowchart.

What is covered

This NICE Pathway covers the early identification and management of chronic kidney disease in adults, children and young people. It includes recommendations on managing anaemia associated with chronic kidney disease and hyperphosphataemia in people with chronic kidney disease.
NICE has produced a COVID-19 rapid guideline on chronic kidney disease. It recommends changes to usual practice to maximise the safety of patients and protect staff from infection during the COVID-19 pandemic.

Updates

Updates to this NICE Pathway

27 October 2021 Percutaneous endovascular forearm arteriovenous fistula creation for haemodialysis access (NICE interventional procedures guidance 710) added to planning treatment.
25 August 2021 Chronic kidney disease (NICE guideline 203) added. Structure revised as this guideline replaces NICE guidelines CG182, CG157 and NG8.
5 August 2020 Electrical stimulation to improve muscle strength in chronic respiratory conditions, chronic heart failure and chronic kidney disease (NICE interventional procedures guidance 677) added to managing symptoms.
12 February 2020 Patiromer for treating hyperkalaemia (NICE technology appraisal guidance 623) added to hyperkalaemia.
3 September 2019 Sodium zirconium cyclosilicate for treating hyperkalaemia (NICE technology appraisal guidance 599) added to hyperkalaemia.
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.
Chronic kidney disease (2021) NICE guideline NG203
Patiromer for treating hyperkalaemia (2020) NICE technology appraisal guidance 623
Sodium zirconium cyclosilicate for treating hyperkalaemia (2019) NICE technology appraisal guidance 599
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
Tegaderm CHG securement dressing for vascular access sites (2020) NICE medtech innovation briefing 231

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 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

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured and can be adapted and used flexibly.
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 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 audiences

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, integrated care systems 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. NICE guideline NG203 (2021), recommendations 1.1.20, 1.1.21 , 1.3.1 and 1.3.4

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:
  • all 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).
Adults at risk of CKD
Adults with any of the following risk factors:
  • diabetes
  • hypertension
  • previous episode of 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
  • gout
  • family history of end-stage renal disease (GFR category G5) or hereditary kidney disease
  • incidental detection of haematuria or proteinuria
  • medicines that can adversely affect kidney function, such as calcineurin inhibitors (for example, cyclosporin or tacrolimus), lithium or non-steroidal anti-inflammatory drugs (NSAIDs).
[NICE’s guideline on chronic kidney disease, recommendations 1.1.20 and 1.1.21, 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, 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, recommendation 1.1.12 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 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
  • the rate of decline in eGFR or increase in ACR (but be aware that CKD progression is often non-linear)
  • other risk factors, including heart failure, diabetes and hypertension
  • changes to their treatment (such as renin–angiotensin–aldosterone system [RAAS] antagonists, NSAIDs and diuretics)
  • intercurrent illness (for example acute kidney injury)
  • whether they have chosen conservative management of CKD.
[Adapted from NICE’s guideline on chronic kidney disease, recommendations 1.3.1 and 1.3.4 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 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

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured and can be adapted and used flexibly.
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 with an ACR below 70 mg/mmol whose systolic blood pressure is between 120 and 139 mmHg and their clinic diastolic blood pressure below 90 mmHg.
Numerator – the number in the denominator whose systolic blood pressure is between 120 and 139 mmHg and their clinic diastolic blood pressure below 90 mmHg.
Denominator – the number of adults with CKD 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 whose systolic blood pressure is between 120 and 129 mmHg and their clinic diastolic blood pressure below 80 mmHg.
Numerator – the number in the denominator whose systolic blood pressure is between 120 and 129 mmHg and their clinic diastolic blood pressure below 80 mmHg.
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 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 and 129 mmHg and their clinic diastolic blood pressure below 80 mmHg.
Numerator – the number in the denominator whose systolic blood pressure is between 120 and 129 mmHg and their clinic 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, integrated care systems 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. NICE guideline NG203 (2021), 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).
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 to 139 mmHg) and the clinic diastolic blood pressure below 90 mmHg.
  • In people with CKD with an ACR of 70 mg/mmol or more, aim to keep the systolic blood pressure below 130 mmHg (target range 120 to 129 mmHg) and the clinic diastolic blood pressure below 80 mmHg.
[Adapted from NICE’s guideline on chronic kidney disease, 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 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

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured and can be adapted and used flexibly.
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.
Healthcare 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, integrated care systems 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 (albumin:creatinine ratio [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).

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

Refer adults with CKD for specialist assessment (taking into account their wishes and comorbidities) if they have any of the following:
Refer people with CKD and renal outflow obstruction to urological services, unless urgent treatment is needed (for example, for hyperkalaemia, severe uraemia, acidosis or fluid overload).
Consider discussing management with a specialist by letter, email, telephone, or virtual meeting, if there are concerns but the person with CKD does not need to see a specialist.

Shared care

After referral:
  • Agree, document and date a care plan with the person with CKD or their family member or carer (as appropriate). Follow:
  • Consider routine follow up at the GP surgery or with a paediatrician rather than in a specialist clinic.
  • Specify criteria for future referral and re-referral if GP follow up is agreed. For children and young people, these criteria should be agreed between the GP and secondary care services.

Rationale and impact

Refer children and young people with CKD for specialist assessment if they have any of the following:
  • an ACR of 3 mg/mmol or more, confirmed on a repeat early morning urine sample
  • haematuria
  • any decrease in eGFR
  • hypertension
  • known or suspected rare or genetic causes of CKD
  • suspected renal artery stenosis
  • renal outflow obstruction.
Refer people with CKD and renal outflow obstruction to urological services, unless urgent treatment is needed (for example, for hyperkalaemia, severe uraemia, acidosis or fluid overload).
Consider discussing management with a specialist by letter, email, telephone, or virtual meeting, if there are concerns but the person with CKD does not need to see a specialist.

Shared care

After referral:
  • Agree, document and date a care plan with the person with CKD or their family member or carer (as appropriate).
  • Consider routine follow up at the GP surgery or with a paediatrician rather than in a specialist clinic.
  • Specify criteria for future referral and re-referral if GP follow up is agreed. For children and young people, these criteria should be agreed between the GP and secondary care services.

Rationale and impact

4-variable Kidney Failure Risk Equation

A person's 5-year risk of needing renal replacement therapy (defined as the need for dialysis or transplant) is estimated, as in Major 2019, as:
1 – 0.9570exp(βsum)
βsum = [- 0.2201*(age/10 – 7.036)] + [0.2467 * (male – 0.5642)] – [0.5567 * (eGFR/5 – 7.222)] + [0.4510 * (log(ACR/0.113) – 5.137)]
In the above, estimated glomerular filtration rate is reported in ml/min/1.73m2 and ACR in mg/mmol. This equation and its coefficients are validated in a UK population, and it is important to use this version, and not a version validated in another country.

Classification of CKD

CKD is classified according to eGFR and ACR, using 'G' to denote the GFR category (G1 to G5, which have the same GFR thresholds as the CKD stages 1 to 5 recommended previously) and 'A' for the ACR category (A1 to 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.

Risk of adverse outcomes in adults by GFR and ACR category

GFR category
ACR category A1: normal to mildly increased (less than 3 mg/mmol)
ACR category A2: moderately increased (3 to 30 mg/mmol)
ACR category A3: severely increased (over 30 mg/mmol)
GFR category G1: normal and high (90 ml/min/1.73m2 or over)
Low risk
No CKD if there are no other markers of kidney damage
Moderate risk
High risk
GFR category G2: mild reduction related to normal range for a young adult (60 to 89 ml/min/1.73m2)
Low risk
No CKD if there are no other markers of kidney damage
Moderate risk
High risk
GFR category G3a: mild to moderate reduction (45 to 59 ml/min/1.73m2)
Moderate risk
High risk
Very high risk
GFR category G3b: moderate to severe reduction (30 to 44 ml/min/1.73m2)
High risk
Very high risk
Very high risk
GFR category G4: severe reduction (15 to 29 ml/min/1.73m2)
Very high risk
Very high risk
Very high risk
GFR category G5: kidney failure (under 15 ml/min/1.73m2)
Very high risk
Very high risk
Very high risk
Abbreviations: ACR, albumin:creatinine ratio; CKD, chronic kidney disease; GFR glomerular filtration rate

Minimum number of monitoring checks (eGFRcreatinine) per year for adults, children and young people with or at risk of chronic kidney disease

GFR category
ACR category A1: normal to mildly increased (less than 3 mg/mmol)
ACR category A2: moderately increased (3 to 30 mg/mmol)
ACR category A3: severely increased (over 30 mg/mmol)
GFR category G1: normal and high (90 ml/min/1.73m2 or over)
0 to 1
1
1 or more
GFR category G2: mild reduction related to normal range for a young adult (60 to 89 ml/min/1.73m2)
0 to 1
1
1 or more
GFR category G3a: mild to moderate reduction (45 to 59 ml/min/1.73m2)
1
1
2
GFR category G3b: moderate to severe reduction (30 to 44 ml/min/1.73m2)
1 to 2
2
2 or more
GFR category G4: severe reduction (15 to 29 ml/min/1.73m2)
2
2
3
GFR category G5: kidney failure (under 15 ml/min/1.73m2)
4
4 or more
4 or more
Note: ACR monitoring should be individualised based on a person's individual characteristics, risk of progression and whether a change in ACR is likely to lead to a change in management.
Abbreviations: ACR, albumin:creatinine ratio; eGFRcreatinine, estimated glomerular filtration rate; GFR, glomerular filtration rate

Example of high-dose intravenous iron regimen for adults

Iron status
Intravenous iron sucrose (high-dose regimen)
First month
600 mg divided equally over 3 haemodialysis sessions
Second month onwards if ferritin 700 micrograms/litre or less
200 mg during each of the first 2 dialysis sessions
Second month onwards if ferritin over 700 micrograms/litre and/or transferrin saturation 40% or more and/or C-reactive protein over 50 mg/litre
Withhold iron dose
Intravenous iron sucrose based on the high-dose iron regimen in the PIVOTAL trial (Macdougall 2019), which included people with serum ferritin below 400 micrograms/litre, a transferrin saturation below 30% and a C-reactive protein below 50 mg/litre and on an erythropoiesis-stimulating agent.
In adults, children and young people with anaemia of CKD, monitor Hb:
  • every 2 to 4 weeks in the induction phase of ESA therapy
  • every 1 to 3 months in the maintenance phase of ESA therapy
  • more frequently after an ESA dose adjustment
  • in a clinical setting chosen in discussion with the person, taking into account their convenience and local healthcare systems.
Optimise iron status before or at the same time as starting ESAs and during maintenance treatment with ESAs.
Use of ACE inhibitors or angiotensin type II receptor antagonists is not precluded, but if they are used, an increase in ESA therapy should be considered.

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.

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

Glossary

angiotensin-converting enzyme
albumin:creatinine ratio
automated peritoneal dialysis
angiotensin-receptor blocker
British national formulary
British national formulary for children
continuous ambulatory peritoneal dialysis
reticulocyte haemoglobin content
(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)
erythropoiesis-stimulating agent
erythropoiesis-stimulating agents
an estimation of glomerular filtration rate using serum creatinine
glomerular filtration rate (either measured or estimated)
haemoglobin
haemodialysis
haemodiafiltration
(maximum of 2 infusions, with a minimum of 500 mg of iron in each infusion for adults)
percentage hypochromic red cells
isotope dilution mass spectrometry
(more than 2 infusions with 100 mg to 200 mg of iron in each infusion for adults)
(these include 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
(usually regarded as CKD stages 4 and 5, although there is no accepted definition, includes people with a failing transplant and people having conservative management)
pure red cell aplasia
parathyroid hormone
renin-angiotensin-aldosterone system
(a medicine 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)
(medicines that block or inhibit the renin–angiotensin–aldosterone system, including angiotensin-converting enzyme [ACE] inhibitors, angiotensin-receptor blockers [ARBs], direct renin inhibitors and aldosterone antagonists)
(a medicine 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 medicines does not include aldosterone antagonists)
(medicines that block or inhibit the renin–angiotensin system including angiotensin-converting enzyme [ACE] inhibitors, angiotensin-receptor blockers [ARBs] and direct renin inhibitors; this group of medicines does not include aldosterone antagonists)
(renal replacement therapy encompasses life-supporting treatments for severe acute kidney injury or stage 5 chronic kidney disease, including haemodialysis, haemofiltration, haemodiafiltration, peritoneal dialysis and kidney transplantation)

Paths in this pathway

Pathway created: May 2011 Last updated: October 2021

© NICE 2021. All rights reserved. Subject to Notice of rights.

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