Chronic Kidney Disease

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The National Collaborating Centre for Chronic ConditionsFunded to produce guidelines for the NHS by NICE

CHRONIC KIDNEY DISEASENational clinical guideline for early identification and management in adults in primary and secondary care

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Royal College of PhysiciansThe Royal College of Physicians plays a leading role in the delivery of high-quality patient care by setting standards of medical practice and promoting clinical excellence. We provide physicians in the United Kingdom and overseas with education, training and support throughout their careers. As an independent body representing over 20,000 Fellows and Members worldwide, we advise and work with government, the public, patients and other professions to improve health and healthcare.

National Collaborating Centre for Chronic ConditionsThe National Collaborating Centre for Chronic Conditions (NCC-CC) is a collaborative, multiprofessional centre undertaking commissions to develop clinical guidance for the National Health Service (NHS) in England and Wales. The NCC-CC was established in 2001. It is an independent body, housed within the Clinical Standards Department at the Royal College of Physicians of London. The NCC-CC is funded by the National Institute for Health and Clinical Excellence (NICE) to undertake commissions for national clinical guidelines on an annual rolling programme.

Citation for this documentNational Collaborating Centre for Chronic Conditions. Chronic kidney disease: national clinical guideline for early identification and management in adults in primary and secondary care. London: Royal College of Physicians, September 2008.

ISBN 978-1-86016-340-1 ROYAL COLLEGE OF PHYSICIANS 11 St Andrews Place, London NW1 4LE Registered charity No 210508 Copyright 2008 Royal College of Physicians of London All rights reserved. No part of this publication may be reproduced in any form (including photocopying or storing it in any medium by electronic means and whether or not transiently or incidentally to some other use of this publication) without the written permission of the copyright owner. Applications for the copyright owners written permission to reproduce any part of this publication should be addressed to the publisher. Typeset by Dan-Set Graphics, Telford, Shropshire Printed in Great Britain by The Lavenham Press Ltd, Sudbury, Suffolk

ContentsGuideline Development Group members Preface Acronyms, abbreviations and glossary v ix x

DEVELOPMENT OF THE GUIDELINE1 1.1 1.2 1.3 2 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 2.10 3 3.1 3.2 Introduction Background Definition Burden of disease Methodology Aim Scope Audience Involvement of people with CKD Guideline limitations Other work relevant to the guideline Background The process of guideline development Disclaimer Funding Key messages of the guideline Key priorities for implementation Algorithms 3 4 5

9 9 9 9 10 10 10 11 15 15

17 19

THE GUIDELINE4 4.1 4.2 4.3 4.4 4.5 5 5.1 5.2 6 6.1 6.2 Investigation of CKD Measurement of kidney function Factors affecting the biological and analytical variability of GFR estimated from measurement of serum creatinine Detection of blood and protein in the urine Urinary albumin:creatinine and protein:creatinine ratios, and their relationship to 24-hour urinary protein Indications for renal ultrasound in the evaluation of CKD Classification and early identification The influence of GFR, age, gender, ethnicity and proteinuria on patient outcomes Who should be tested for CKD? Defining progression of CKD and the risk factors associated with progression Defining progression Risk factors associated with progression of CKD 25 30 33 41 47

51 59

73 78


Chronic kidney disease

7 7.1 8 8.1 8.2 9 9.1 9.2 9.3 9.4 9.5 10 10.1 10.2 10.3 11 11.1 12 12.1 13 13.1 13.2 13.3 14 14.1 15 15.1 15.2

Referral criteria Indications for referral to specialist care Self management Modification of lifestyle Dietary intervention and renal outcomes Blood pressure control Blood pressure control in people with CKD Choice of anti-hypertensive agents for blood pressure control in people with CKD Practicalities of treatment with ACEI/ARBs in people with CKD Considerations of age in prescription of ACEI/ARB therapy The role of aldosterone antagonism in people with CKD Reducing cardiovascular disease Statin therapy and reduction in proteinuria Lipid lowering in people with CKD Anti-platelet therapy and anti-coagulation in people with CKD Asymptomatic hyperuricaemia Asymptomatic hyperuricaemia in people with CKD Managing isolated microscopic haematuria Isolated invisible (microscopic) haematuria Specific complications of CKD renal bone disease Monitoring of calcium, phosphate, vitamin D and parathyroid hormone levels in people with CKD Risks and benefits of bisphosphonates for preventing osteoporosis in adults with CKD Vitamin D supplementation in people with CKD Specific complications of CKD anaemia Anaemia identification in people with CKD Information needs Information, education and support for people with CKD and their carers Available tools to aid identification and maximise effectiveness of treatment and management of CKD


89 95

101 111 123 126 129 133 135 139 145 147 149 155 160 175 177 182

REFERENCES APPENDICES online only at:A B C D Evidence-based clinical questions and literature searches Scope of the guideline Health economic model Cost effectiveness of CKD case finding among people at high risk GDG members declaration of interests



Guideline Development Group membersDr David Halpin, NCC-CC (Chair) Consultant Thoracic Physician Dr Paul Stevens, Clinical Advisor Consultant Nephrologist Ms Lina Bakhshi, NCC-CC Information Scientist Dr Ivan Benett General Practitioner Dr Emily Crowe, NCC-CC Research Fellow Dr Miranda Dodwell Patient and Carer Representative Mr Robert Dunn Patient and Carer Representative Ms Caroline Forrest Practice Nurse Dr Lawrence Goldberg Consultant Nephrologist Dr Kevin PG Harris Consultant Nephrologist Dr Ian John Consultant Nephrologist Dr Edmund Lamb Consultant Biochemist Ms Natasha McIntyre Research Fellow in renal medicine Dr Suffiya Omarjee, NCC-CC Health Economist from August 2007 until March 2008 Dr Shelagh ORiordan Consultant Geriatrician Professor Paul Roderick Reader in Public Health Dr David Stephens General Pracitioner Ms Jaim Sutton, NCC-CC Project Manager until March 2008 Ms Meiyin Tok, NCC-CC Health Economist until August 2007v

Chronic kidney disease

The following were invited to attend specific meetings and to advise the GDG: Dr Claire Beeson acted as a deputy for Dr Shelagh ORiordan at a GDG meeting. Dr Indranil Dasgupta, Consultant Nephrologist, invited to contribute at a specific meeting as an expert representing the Type 2 Diabetes Guideline but was not a full member of the GDG. Dr Patrick Fitzgerald acted as a deputy for Dr Ivan Benett at a GDG meeting. Dr Neil Iggo, Consultant Nephrologist, acted as a deputy for Dr Lawrence Goldberg at a GDG meeting. Dr Kanchana Imrapur acted as a deputy for Dr David Stephens at a GDG meeting. Dr Marta Lapsley acted as a deputy for Dr Edmund Lamb at a GDG meeting. Ms Nicola Thomas acted as a deputy for Ms Natasha McIntyre at a GDG meeting.



AcknowledgementsThe Guideline Development Group is grateful to the following people for their valuable contributions to the development of this guideline: q Dr Bernard Higgins, Director, NCC-CC q Ms Jane Ingham, Assistant Director, NCC-CC q Ms Susan Tann, Centre Co-ordinator, NCC-CC q Ms Jill Parnham, Associate Director, NCC-CC q Ms Diane Green, Dietician q Mr Rob Grant, Senior Technical Advisor, NCC-CC q Ms Claire Turner, Senior Project Manager, NCC-CC q Ms Taryn Krause, Project Manager, NCC-CC Thanks also to the following NCC-CC research fellows: Anu Garrib, Rachel OMahony, Jose Diaz, Roberta Richey and Sharon Swain.


PrefaceChronic kidney disease (CKD) is of growing importance in the UK. The NHS is increasingly focussing on prevention and on the early detection and treatment of potentially progressive disease, whilst the prevalence of risk factors for CKD, such as diabetes, obesity and hypertension is rising. It is therefore a great pleasure to introduce this timely new guideline on CKD from the National Collaborating Centre for Chronic Conditions (NCC-CC) and the National Institute for Health and Clinical Excellence (NICE). The recommendations you will read here are the result of a thorough review of the published research. The field of renal medicine has a complex evidence base, and enormous thanks are due to the Guideline Development Group for their hard work and attention to detail, and to the NCC-CC Technical Team who worked enthusiastically alongside them. As for all our guidelines, full evidence tables summarising the clinical evidence base, and full details of the health economic modelling, are available from the Royal College of Physicians website. Readers involved in research in this field, and those who want to find the full rationale behind a particular recommendation, will find this an invaluable resource. The Department of Health, in commissioning this guideline, was clear that the focus was to be on early detection and management. This is the area in which the guideline can deliver its greatest potential benefit, through delaying progression of disease and thus reducing the need for dialysis or transplantation. The key priority recommendations singled out in the guideline reflect this emphasis. They present clear criteria for testing for CKD, suspecting progressive CKD, and referring people for specialist assessment, all of which should be useful in primary care. Recommendations are also provided on starting