What this presentation covers Background Key priorities for implementation Costs and savings Discussion Find out more
CKD quality standard In 2011 NICE published a quality standard on the diagnosis, care and treatment of chronic kidney disease in adults. Quality standards are a set of specific, concise statements that act as markers of high quality, cost- effective patient care across a pathway or clinical area. This work is central to supporting the Government's vision for an NHS focused on delivering the best possible outcomes for patients.
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.
Classification Stages of chronic kidney disease (updated) Stage a GFR (ml/min/1.73 m 2 ) Description 1 90 Normal or increased glomerular filtration rate (GFR), with other evidence of kidney damage 260–89Slight decrease in GFR, with other evidence of kidney damage 3A45–59Moderate decrease in GFR with or without other evidence of kidney damage 3B30–44 415–29Severe decrease in GFR, with or without other evidence of kidney damage 5< 15Established renal failure a Use suffix (p) to denote presence of proteinuria when staging CKD
Classification (contd) Stage 3 CKD should be split into two subcategories 3A: GFR 45–59 ml/min/1.73 m 2 3B: GFR 30–44 ml/min/1.73 m 2 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 kidney function 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 minimises incorrect 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 ACR levelOver 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 g/24 h or more 1 g/24 h or more CKD confirmation required Not needed Required Hypertension confirmation required 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 (contd) 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 costs Costs (£ per year) Albumin-creatinine ratio to test for proteinuria in those with eGFR <604,292 The testing of patients with a risk factor for CKD27,760 Estimated cost of implementation32,052
For discussion What tests are currently used to identify proteinuria? How can we improve the way we talk to people about CKD? How can we improve self-care for people with CKD? How can primary care practitioners minimise progression in people with CKD?
Find out more Chronic kidney disease quality standard via Visit for:www.nice.org.uk/cg073 Other guideline formats Costing report and template Audit support Guide to resources BMJ Learning online educational tool