Presentation on theme: "Chronic kidney disease"— Presentation transcript:
1 Chronic kidney disease Implementing NICE guidanceABOUT THIS PRESENTATION:This presentation has been written to help you raise awareness of the NICE clinical guideline on chronic kidney disease: early identification and management of chronic kidney disease in adults in primary and secondary care. This guideline has been written for primary and secondary NHS healthcare, including referral to tertiary care.The guideline is available in a number of formats. You can download these from the NICE website or order printed copies of the quick reference guide by calling NICE publications on or sending an to Quote reference number N1686. You may want to hand out copies of the quick reference guide at your presentation so that your audience can refer to it.You can add your own organisation’s logo alongside the NICE logo. We have included notes for presenters to help highlight key points to raise in your presentation and to provide supplementary information to the slides. Where necessary, the recommendation will be given in full. Please feel free to adapt, amend or remove these as you see necessary.DISCLAIMERThis slide set is an implementation tool and should be used alongside the published guidance. This information does not supersede or replace the guidance itself.2008NICE clinical guideline 73
2 What this presentation covers BackgroundKey priorities for implementationCosts and savingsDiscussionFind out moreNOTES FOR PRESENTERS:In this presentation we will start by providing a definition of the guideline scope and why it is important.The NICE guideline contains seven key priorities for implementation, which you can find in your quick reference guide.The key priorities for implementation cover the following areas:Early identification of Chronic kidney disease (CKD)InvestigationClassification of CKDReferral criteriaCKD progressionPharmacotherapyBlood pressure monitoringThere are also additional slides covering the measurement of renal function and CKD patient information and education. These are not key recommendations, but are integral to the care and management of people with CKD.The costs and savings that are likely to be incurred in implementing the guideline are summarised, followed by a list of suggested questions to help prompt discussion.Information on how to find out more about the implementation support provided by NICE is given at the end of this presentation.
3 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.NOTES FOR PRESENTERS:Key points to raise:The NICE guideline covers best practice advice on identifying adults who either have or who are at risk of developing CKD, and interventions to slow or prevent the progression of the disease.CKD has an asymptomatic period, but it can still be detected during this time using a simple test. Because of a lack of specific symptoms, people with CKD are often not diagnosed, or diagnosed late when CKD is at an advanced stage.Previously up to 30 per cent of people with advanced kidney disease had been referred late to nephrology services from primary and secondary care, although data from the UK Renal Registry annual report (2007) now points to a sustained and significant reduction in late referrals to nephrology services.Additional information:People with CKD carry a higher risk of cardiovascular disease.Diabetes is a key risk factor for CKD; around 31% of people diagnosed with diabetes also have CKD.Hypertension is linked as a risk factor to CKD.Over 2% of the total NHS budget is spent on renal replacement therapy.Some conditions that coexist with CKD become more severe as kidney dysfunction advances.CKD can progress to established renal failure in a small but significant percentage of people.Advanced CKD carries a high mortality risk, and the risk of CKD developing increases with age.Late referral of those diagnosed with CKD increases risks of mortality and morbidity and precludes assessment and preparation of those for whom conservative management is more appropriate.Significant costs and poor clinical outcomes are associated with the late referral of people with end-stage renal failure who require renal replacement therapy. Identification of people at earlier stages of CKD, and appropriate management and earlier referral of those who would benefit from specialist renal services would increase both economic and clinical effectiveness.
5 Classification Stages of chronic kidney disease (updated) Stagea GFR (ml/min/1.73 m2)Description1 90Normal or increased glomerular filtration rate (GFR), with other evidence of kidney damage260–89Slight decrease in GFR, with other evidence of kidney damage3A45–59Moderate decrease in GFR with or without other evidence of kidney damage3B30–44415–29Severe decrease in GFR, with or without other evidence of kidney damage5< 15Established renal failureNOTES FOR PRESENTERS:Key points to raise:The NICE guidance updates stage 3 of the classification of CKD adopted by the ‘National service framework for renal services’. This classification system originated from the American ‘National Kidney Foundation Kidney disease outcomes quality initiative’ (NKF-KDOQI).At the time of publication of the NICE guidance, the US CKD stage 3 classification standard had not been updated and was still undivided.Evidence of kidney damage can include either: the presence of persistent albuminuria, persistent proteinuria or persistent haematuria in urine; structural abnormalities of the kidneys demonstrated on ultrasound scanning or other radiological tests; or biopsy-proven chronic glomerulonephritis.Studies examined in the full guideline have underlined the importance of proteinuria/albuminuria as an independent risk factor for adverse outcomes in CKD, suggesting an adoption of a ‘p’ suffix in the different stages.At any stage of CKD, management should not be influenced solely by age.Additional information:When staging CKD define proteinuria as urinary ACR 30 mg/mmol, or PCR 50 mg/mmol.The classification of stages of CKD within the NICE guideline apply to those aged 16 years and over.More details on the division of stage 3 into 3A and 3B are on the next slide.The recommendation is provided in full on the following slide.a Use suffix (p) to denote presence of proteinuria when staging CKD
6 Classification (cont’d) Stage 3 CKD should be split into two subcategories3A: GFR 45–59 ml/min/1.73 m23B: GFR 30–44 ml/min/1.73 m2Existing classification of five stages for CKD may not be sufficiently sophisticated for clinical needsNOTES FOR PRESENTERS:Key points to raise:The UK consensus conference on early CKD recommended subclassifying CKD stage 3 into two groups: 3A, which defines a lower-risk group with GFR 45–59ml/min/1.73m2, and 3B, which defines a higher-risk group with GFR 30–44ml/min/1.73m2.The NICE Guidance Development Group considered the evidence and found the risk of mortality and cardiovascular events increased considerably when the GFR was less than 45 ml/min/1.73 m2. This led to the proposal that stage 3 CKD should be split into two substages, outlined on the slide above.Additional information:In people aged over 70 years, an eGFR in the range 45–59 ml/min/1.73 m2, if stable over time and without any other evidence of kidney damage, is unlikely to be associated with CKD-related complications.Recommendation in full:Stage 3 CKD should be split into two subcategories defined by:GFR 45–59 ml/min/1.73 m2 (stage 3A)GFR 30–44 ml/min/1.73 m2 (stage 3B).
7 Early identificationOffer testing for CKD where the following risk factors are present:diabeteshypertensioncardiovascular diseasestructural renal tract diseaserenal calculiprostatic hypertrophymultisystem diseases with potential kidney involvementopportunistic detection of haematuria or proteinuriafamily history of stage 5 CKD or hereditary kidney diseaseNOTES FOR PRESENTERS:Key points to raise:All people in the at-risk groups listed should be tested annually.The quality and outcomes framework includes a diabetes management indicator that is relevant to testing for CKD. DM 14 refers to patients with diabetes who have a recorded test of serum creatinine within the previous 15 months.Whenever a serum creatinine measurement is made, clinical laboratories should report an eGFR using a prediction equation such as the IDMS-traceable simplified MDRD equation. (IDMS = isotope dilution mass spectrometry; MDRD = modification of diet in renal disease) The following two slides provides more information on CKD testing.Monitor GFR in people prescribed drugs known to be nephrotoxic such as calcineurin inhibitors and lithium.Check GFR at least annually in people receiving long-term systemic non-steroidal anti-inflammatory drug (NSAID) treatment.Additional information:In the absence of the risk factors outlined on the slide above, do not use age, gender or ethnicity as risk markers to test people for CKD.In the absence of metabolic syndrome, diabetes or hypertension, do not use obesity alone as a risk marker to test people for CKD.People with CKD should be offered high-quality information or education programmes at appropriate stages of their condition to allow time for them to fully understand and make informed choices about their treatment.Cardiovascular disease includes ischaemic heart disease, chronic heart failure, peripheral vascular disease and cerebral vascular disease.Multisystem diseases with potential kidney involvement include, for example, systemic lupus erythematosus.Monitor GFR in people prescribed nephrotoxic drugs
8 Measurement of kidney function Clinical laboratories should:report estimated GFR (eGFR) when serum creatinine is measuredcorrect for ethnicityInterpret eGFR with caution at extremes of muscle massIn new cases of reduced eGFR confirm by retesting within 2 weeksUrgent despatch and testing of blood minimises incorrect resultsNOTES FOR PRESENTERS:Note – these are not key recommendations, but are an essential part of the care pathwayKey points to raise:Use the prediction equation IDMS-traceable simplified MDRD to estimate GFR, using creatinine assays with calibration traceable to a standardised reference material.Ideally creatinine assays that are specific and zero biased compared with IDMS should be used (for example, enzymatic assays).When non-specific assays are used (for example, Jaffe assays), employ adjustment factors to minimise between-laboratory variation (for example, those provided by national external quality assessment schemes).Where indicated, apply a correction factor for ethnicity to reported GFR values.Avoid delaying the despatch of blood samples to ensure that they are received and processed by the laboratory within 12 hours of venepuncture.Advise people to avoid meat for 12 hours before a blood test for GFR estimation.Additional information:Where eGFR is simply reported as 60 ml/min/1.73 m2 or more, use a rise of more than 20% in serum creatinine concentration to infer significant reduction in renal function.Gold standard methods of assessing GFR are unsuitable for widespread identification of CKD in the ‘at-risk’ population, but may be applied in particular situations where a highly accurate measure of GFR is required – for example, during monitoring of chemotherapy (testing would use a filtration marker that may include inulin, 51Cr-EDTA, 125I-iothalamate or iohexol).Interpret reported values of eGFR of 60 ml/min/1.73 m2 or more with caution – GFR estimates become less accurate as the true GFR increases.Recommendations 1.1.1, and in full:Whenever a request for serum creatinine measurement is made, clinical laboratories should report an estimate of GFR (eGFR) using a prediction equation (see recommendation 1.1.2) in addition to reporting the serum creatinine result (1.1.1).In cases where there are extremes of muscle mass – for example, in bodybuilders, amputees or people with muscle wasting disorders – interpret the eGFR with caution. (Reduced muscle mass will lead to overestimation and increased muscle mass to underestimation of the GFR.) (1.1.7).Advise people not to eat any meat in the 12 hours before having a blood test for GFR estimation. Avoid delaying the despatch of blood samples to ensure that they are received and processed by the laboratory within 12 hours of venepuncture. (1.1.8).
9 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 proteinuriaFor quantification and monitoring of proteinuria, PCR can be used as an alternativeACR is the recommended method for people with diabetesNOTES FOR PRESENTERS:Key points to raise:There are no published comparisons between ACR and protein:creatinine ratio (PCR).Albumin is the principal component of proteinuria in glomerular disease.Do not use reagent strips to identify proteinuria unless they are capable of specifically measuring albumin at low concentrations and expressing the result as an ACR. Reagent strips in current clinical practice predominantly detect albumin, not total protein, but are not reliably quantitative.ACR has far greater sensitivity than PCR for the detection of low levels of proteinuria, enhances early identification of CKD, and importantly, cardiovascular risk in people with CKD begins to increase at low levels of albuminuria (below the sensitivity limits of PCR).There may be clinical reasons for a specialist to subsequently use PCR to quantify and monitor significant levels of proteinuria.Additional information:If the ACR is 30 mg/mmol or more and less than 70 mg/mmol this should be confirmed by a subsequent early morning sample.If initial ACR is 70 mg/mmol or more a repeat sample need not be tested.Some nephrologists disagree about the relative merits of ACR and PCR testing.
10 CKD progression Steps to identify progressive CKD obtain a minimum of three eGFR over not less than 90 daysin new cases of reduced eGFR, repeat within 2 weeks to exclude acute deterioration of GFRCKD 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 yearsNOTES FOR PRESENTERS:Key points to raise:Acute deterioration of GFR may include acute kidney injury or initiation of angiotensin-converting enzyme inhibitor (ACE inhibitor)/angiotensin-II receptor blocker (ARB) therapy.An eGFR result less than 60 ml/min/1.73 m2 in a person not previously tested should be confirmed by repeating the test within 2 weeks.Focus on those where decline of GFR at observed rate would lead to renal replacement therapy within their lifetime by extrapolating the current rate of decline.Work with people who have the following risk factors for progression of CKD to optimise their health: cardiovascular disease; proteinuria; hypertension; diabetes; smoking; black or Asian ethnicity; chronic use of NSAIDS; urinary outflow tract obstruction.Additional information:People with CKD should be offered education and information tailored to the stage and cause of CKD, the associated complications and the risk of progression.The chronic use of NSAIDs may be associated with progression of CKD and acute use is associated with a reversible fall in GFR.Exercise caution when treating people with CKD with NSAIDs over prolonged periods of time. Monitor the effects on GFR, particularly in people with a low baseline GFR and/or in the presence of other risks for progression.For patients with access to the internet, the Renal Patient View system may provide a convenient means of accessing the results of their blood tests and information about their diagnosis and treatment.Recommendation in full:Take the following steps to identify progressive CKD:Obtain a minimum of three GFR estimations over a period of not less than 90 days; in people with a new finding ofreduced eGFR, repeat the eGFR within 2 weeks to exclude causes of acute deterioration of GFR – for example, acutekidney injury or initiation of ACE inhibitor/ARB therapy; define progression as a decline in eGFR of more than 5ml/min/1.73 m2 within 1 year, or more than 10 ml/min/1.73 m2 within 5 years; focus particularly on those in whom a declinein GFR continuing at the observed rate would lead to the need for renal replacement therapy within their lifetime byextrapolating the current rate of decline.
11 Referral criteriaRefer the following people with CKD for discussion or specialist assessment:stage 4 and 5 CKD (with or without diabetes)higher levels of proteinuriaproteinuria together with haematuriarapidly declining eGFRpoorly controlled hypertensionpeople with rare or genetic causes of CKDsuspected renal artery stenosisNOTES FOR PRESENTERS:Key points to raise:Take into account the individual’s wishes and comorbidities when considering referral.Consider discussing management issues with a specialist by letter, or telephone in cases where it may not be necessary for the person with CKD to be seen by the specialist; referral does not necessarily mean a patient attends an out-patient clinic.Once an individual’s case has been discussed or assessed with a specialist clinic and a management plan agreed, it may be possible for their care to be carried out by the referring clinician.Specialist care can be provided by geriatricians, diabetologists, cardiologists, nephrologists, specialist nurses and GPs.Additional information:Higher levels of proteinuria are defined as ACR 70 mg/mmol or more, equivalent to PCR 100 mg/mmol or more, or urinary protein excretion 1 g/24 h or more – unless level is known to be because of diabetes and already appropriately treated.Where proteinuria is present with haematuria, a referral to specialist assessment should be made where levels are at ACR 30 mg/mmol or more, approximately equivalent to PCR 50 mg/mmol or more, or urinary protein excretion 0.5 g/24 h or more.Persistent, invisible haematuria in the absence of proteinuria should be followed up annually with repeat testing for haematuria, proteinuria/albuminuria and blood pressure monitoring as long as the haematuria persists.When testing for presence of haematuria, use reagent strips rather than urine microscopy. Evaluate further if there is a result of 1+ or more.Do not use urine microscopy to confirm a positive result.People with CKD who have visible or persistent invisible haematuria should be offered a renal ultrasound.A rapidly declining estimate of GFR is more than 5 ml/min/1.73 m2 in 1 year, or more than 10 ml/min/1.73 m2 within 5 years.If hypertension remains poorly controlled despite using at least four antihypertensive drugs at therapeutic doses a referral for specialist assessment should take place (see ‘Hypertension: management of hypertension in adults in primary care’ [NICE clinical guideline 34]).Routine follow-up can 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.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.
12 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 mmHgIn 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 mmHgNOTES FOR PRESENTERS:Key points to raise:These blood pressure ranges relate to patients with identified CKD.NICE guidance developers appraised evidence on blood pressure control, but did not set out to establish definitive safe ranges of blood pressure in CKD. Existing hypertension guidelines such as the NICE hypertension guideline (NICE clinical guideline 34) give a range rather than just an upper limit. The GDG therefore set out a range of blood pressure targets, given in these recommendations, which in their clinical experience will inform good practice in CKD.The QOF blood pressure indicator for CKD is 140/85 mmHg (2008/09 QOF).
13 PharmacotherapyACE inhibitors (or ARBs*) should be offered to the following peopleMan with diabetesWoman with diabetesNon-diabetic adultACR levelOver 2.5 mg/ mmolOver 3.5 mg/ mmol30 mg/mmol or more70 mg/mmol or morePCR level--50 mg/mmol or more100 mg/mmol or more24 h urinary protein0.5 g/24 hor more1 g/24 hCKD confirmation requiredNot neededRequiredHypertension confirmation requiredNOTES FOR PRESENTERS:Key points to raise:ACE inhibitors (or ARBs) should be provided to people within the groups outlined above.ACE inhibitors are: angiotensin-converting enzyme inhibitors. ARBs are: angiotensin-II receptor blockers.ACE inhibitor should be a first-line treatment; move to an ARB if ACE is not tolerated.In people with diabetes, ACE inhibitors (or ARBs) should be offered irrespective of CKD stage or the presence of hypertension.Serum potassium concentrations and an eGFR should be measured before starting ACE inhibitor/ARB therapy.Measurements should be repeated between 1 and 2 weeks after starting ACE inhibitor/ARB therapy and after each dose increase.Non-diabetic people with CKD and hypertension and ACR less than 30 mg/mmol should be offered a choice of antihypertensive treatment according to the NICE guidance on hypertension (NICE clinical guideline 34) to prevent or ameliorate progression of CKD.Additional information:The intervention threshold for non-diabetic people with CKD and hypertension is approximately equivalent to urinary protein excretion 0.5 g/24 h or more.Two different ACR thresholds are given in the guideline for initiating ACE inhibitor treatment in people with CKD and proteinuria. The potential benefit of ACE inhibitors in this context is greatly increased if the person also has diabetes or hypertension, and in these circumstances, a lower threshold is applied.Treatment for people with CKD should also include interventions to reduce cardiovascular risk by encouraging regular exercise, to achieve a healthy weight and to stop smoking.The table above should be read with reference to the NICE quick reference guide.*ACE inhibitor should be a first line treatment; move to an ARB if ACE is not tolerated
14 Other recommendations Offer a renal ultrasound to all people with CKD who:have progressive CKDhave visible or persistent invisible haematuriahave symptoms of urinary tract obstructionhave a family history of polycystic kidney disease and are aged over 20have stage 4 or 5 CKDare considered by a nephrologist to require a renal biopsyNOTES FOR PRESENTERS:Note – these are not key recommendations, but are an essential part of the care pathwayAdvise people with a family history of inherited kidney disease about the implications of an abnormal result before arranging their scan.Recommendations and in full:Offer a renal ultrasound to all people with CKD who: have progressive CKD (eGFR decline more than 5 ml/min/1.73 m2 within 1 year, or more than 10 ml/min/1.73 m2 within 5 years); 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.Advise people with a family history of inherited kidney disease about the implications of an abnormal result before a renal ultrasound scan is arranged for them.
15 Other recommendations (cont’d) Provide people with CKD:high quality education at appropriate stages of their condition to enable informed treatment choicestailored information to their stage and cause of CKDInformation and education programmes should be provided by healthcare professionals with specialist knowledge of CKD and the skills to facilitate learningNOTES FOR PRESENTERS:Note – these are not key recommendations, but are an essential part of the care pathwayKey points to raise:When developing information or education programmes, involve people with CKD in their development from the outset.The following topics are suggested:What is CKD and how does it affect people? What questions should people ask about their kidneys when they attend clinic? What treatments are available for CKD, what are their advantages and disadvantages and what complications or side effects may occur as a result of treatment/medication? What can people do to manage and influence their own condition?In what ways could CKD and its treatment affect people’s daily life, social activities, work opportunities and financial situation, including benefits and allowances available?How can people cope with and adjust to CKD and what sources of psychological support are available? When appropriate, offer information about renal replacement therapy (such as the frequency and length of time of dialysis treatment sessions or exchanges and pre-emptive transplantation) and the preparation required (such as having a fistula or peritoneal catheter).Conservative management may be considered where appropriate.Additional information:Further patient information and resources can be found atRecommendation and in full:Offer people with CKD high quality information or education programmes at appropriate stages of their condition to allow time for them to fully understand and make informed choices about their treatment.Healthcare professionals providing information and education programmes should ensure they have specialist knowledge about CKD and the necessary skills to facilitate learning.
16 Estimated costs per 100,000 population Recommendations with significant costsCosts(£ per year)Albumin-creatinine ratio to test for proteinuria in those with eGFR <604,292The testing of patients with a risk factor for CKD27,760Estimated cost of implementation32,052ADAPTING THIS SLIDE FOR LOCAL USE:We are aware that local factors such as incidence and baseline can vary considerably when compared with the national average. NICE has provided a costing template for you to calculate the financial impact this guideline will have locally. We encourage you to calculate the local impact of this guideline by amending the local variations in the template such as incidence, baseline and uptake. You can then remove the national figures from the table and replace them with your local figures to present to your colleagues.NOTES FOR PRESENTERS:The information on this slide has been extracted from the NICE costing report, which has been provided by NICE to support implementation of this guidance. It was developed after careful consideration of the available data and by working closely with the guideline developers and other people in the NHS. It is not NICE guidance. Assumptions used in this report are based on assessment of the national average and it is recognised that local practice or circumstances may differ from this. The costs published in this report are estimates only and are not to be taken as the Institute's view of desirable, or maximum or minimum figures.NICE has also provided a costing template to help calculate the local costs associated with implementing this guideline. The costs per 100,000 population are summarised in the table.Key Points to raise:The NICE CKD costing report focuses on recommendations considered to have the greatest resource impact, which would require the most additional resources to implement or potentially generate savings. These recommendations refer to: albumin:creatinine ratio (ACR) testing for proteinuria; and testing people with risk factor(s) for CKD.Anecdotal evidence suggests that some health communities already prefer to use ACR testing to identify proteinuria in primary care.Testing people who have risk factors for CKD is likely to detect additional people who have CKD. Identifying these additional people in this way may result in an increase in prescribing (for those not already receiving medication for any comorbidity).Additional information:Implementing the clinical guideline will bring the following benefits:a reduction in hospitalisation through the earlier identification of patients; identification of patients at increased risk of premature CVD, and the opportunity to improve CVD prevention therapy; a delay in the progression to end stage renal failure (haemodialysis is estimated to cost £29,800 per patient annually).Please see the costing report for full details of how these calculations have been made.It is recognised that implementation of the recommendations may take place over a number of years.For further information please refer to the costing template and costing report for this guidance on the NICE website.Compliance with NICE guidance is one of the criteria indicating good risk reduction strategies, and in combination with meeting other criteria could lead to a discount on contributions to the NHS Litigation Authority schemes, including the clinical negligence scheme for trusts (CNST).
17 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?NOTES FOR PRESENTERS:These questions are suggestions that have been developed to help provide a prompt for a discussion at the end of your presentation – please edit and adapt these to suit your local situation.
18 Find out more Visit www.nice.org.uk/cg073 for: Other guideline formats Costing report and templateAudit supportGuide to resourcesVisit for information on the Department of Health Kidney Care programme Visit for information on the Department of Health renal policy programmeNOTES FOR PRESENTERS:The guideline is available in a number of formats.The quick reference guide – which summarises the guidance.The NICE guideline – which includes all of the recommendations in full.The full guideline – which includes all of the evidence and rationale.‘Understanding NICE guidance’ – a version for patients and carers.This slide set was produced in collaboration with the Department of Health Kidney Care team.You can download these from the NICE website or order printed copies of the quick reference guide and ‘Understanding NICE guidance’ by calling NICE publications on or by sending an to Quote reference number N1686. You may want to hand out copies of the quick reference guide at your presentation so that your audience can refer to it.NICE has developed tools to help organisations implement this guideline, which can be found on the NICE website.Costing tools – a costing report gives the background to the national savings and costs associated with implementation, and a costing template allows you to estimate the local costs and savings involved.Audit support – assists NHS trusts to determine how well they meet NICE recommendations.Guide to resources - signposts a selection of resources available from NICE, government and other national organisations