Chronic kidney disease
Implementing NICE guidance
2008
NICE clinical guideline 73
What this presentation covers
Background
Key priorities for implementation
Costs and savings
Discussion
Find out more
Background
1 in 10 people in the UK have chronic kidney disease (CKD)
Treatment can prevent or delay the progression of CKD and reduce the risk of cardiovascular disease.
CKD is frequently unrecognised, often existing with other conditions such as cardiovascular disease or diabetes.
30% of patients with advanced CKD are referred late to nephrology services from primary and secondary care.
Background (cont’d)
Copyright © 2007 QRESEARCH and The Information Centrefor health and social care
Growth in recognition of Chronic kidney disease
Classification
Stages of chronic kidney disease (updated)
Stagea GFR (ml/min/1.73m2)
Description
1 90 Normal or increased glomerular filtration rate (GFR), with other evidence of kidney damage
2 60–89 Slight decrease in GFR,with other evidence of kidney damage
3A 45–59 Moderate decrease in GFRwith or without other evidence of kidney damage3B 30–44
4 15–29 Severe decrease in GFR, with or without other evidence of kidney damage
5 < 15 Established renal failure
a Use suffix (p) to denote presence of proteinuria when staging CKD
Classification (cont’d)
•Stage 3 CKD should be split into two subcategories
3A: GFR 45–59 ml/min/1.73 m2
3B: GFR 30–44 ml/min/1.73 m2
Existing classification of five stages for CKD may not be sufficiently sophisticated for clinical needs
Early identification
• Offer testing for CKD where the following risk factors are present:
diabetes
hypertension
cardiovascular disease
structural renal tract disease
renal calculi
prostatic hypertrophy
multisystem diseases with potential kidney involvement
opportunistic detection of haematuria or proteinuria
family history of stage 5 CKD or hereditary kidney disease
• Monitor GFR in people prescribed nephrotoxic drugs
Measurement of kidneyfunction
Clinical laboratories should:
• report estimated GFR (eGFR) when serum creatinine is measured
• correct for ethnicity
Interpret eGFR with caution at extremes of muscle mass
In new cases of reduced eGFR confirm by retesting within 2 weeks
Urgent despatch and testing of blood minimisesincorrect results
Testing for proteinuria• To detect and identify proteinuria, use urine
albumin:creatinine ratio (ACR) in preference,as it has greater sensitivity than protein:creatinine ratio (PCR) for low levels of proteinuria
• For quantification and monitoring of proteinuria,PCR can be used as an alternative
• ACR is the recommended method for people with diabetes
CKD progression
•Steps to identify progressive CKD– obtain a minimum of three eGFR over not less than 90 days– in new cases of reduced eGFR, repeat within 2 weeks
to exclude acute deterioration of GFR
• CKD progression is either a decline in eGFR: of > 5 ml/min/1.73 m2 within 1 year or > 10 ml/min/1.73 m2 within 5 years
Referral criteria
• Refer the following people with CKD for discussion or specialist assessment:
stage 4 and 5 CKD (with or without diabetes)
higher levels of proteinuria
proteinuria together with haematuria
rapidly declining eGFR
poorly controlled hypertension
people with rare or genetic causes of CKD
suspected renal artery stenosis
Blood pressure control
• In people with CKD aim for:
systolic blood pressure below 140 mmHg(target range 120–139 mmHg)
diastolic blood pressure below 90 mmHg
• In people with CKD and diabetes - or when ACR 70mg/mmol, aim for:
systolic blood pressure below 130 mmHg(target range 120–129 mmHg)
diastolic blood pressure below 80 mmHg
Pharmacotherapy
ACE inhibitors (or ARBs*) should be offered to the following people
*ACE inhibitor should be a first line treatment; move to an ARB if ACE is not tolerated
Man with diabetes
Woman with diabetes
Non-diabetic adult
Non-diabetic adult
ACR level Over 2.5 mg/mmol
Over 3.5 mg/mmol
30 mg/mmol or more
70 mg/mmol or more
PCR level -- -- 50 mg/mmol or more
100 mg/mmol or more
24 h urinary protein
-- -- 0.5 g/24 hor more
1 g/24 hor more
CKD confirmation required
Not needed Not needed Required Required
Hypertension confirmation required
Not needed Not needed Required Not needed
Other recommendations
• Offer a renal ultrasound to all people with CKD who:
have progressive CKD
have visible or persistent invisible haematuria
have symptoms of urinary tract obstruction
have a family history of polycystic kidney disease and are aged over 20
have stage 4 or 5 CKD
are considered by a nephrologist to require a renal biopsy
Other recommendations (cont’d)
•Provide people with CKD:
high quality education at appropriate stages of their condition to enable informed treatment choices
tailored information to their stage and cause of CKD
• Information and education programmes should be provided by healthcare professionals with specialist knowledge of CKD and the skills to facilitate learning
Estimated costs per 100,000 population
Recommendations with significant costsCosts
(£ per year)
Albumin-creatinine ratio to test for proteinuriain those with eGFR <60 4,292
The testing of patients with a risk factor for CKD 27,760
Estimated cost of implementation 32,052
For discussion
What tests are currently used to identify proteinuria?
How can we improve the way we talk to patients about CKD?
How can we improve self-care for patients with CKD?
How can primary care practitioners minimise CKD progression in patients?
Find out more
Visit www.nice.org.uk/cg073 for:
•Other guideline formats•Costing report and template•Audit support•Guide to resources
Visit www.kidneycare.nhs.uk for information on theDepartment of Health Kidney Care programme
Visit www.dh.gov.uk/renal for information on the Department of Health renal policy programme