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