Excerpt

Publication of the second part of the Renal National Service Framework (NSF) served to emphasise the change in focus in renal medicine from treatment of established kidney disease to earlier identification and prevention of kidney disease. Allied to this is the knowledge that late referral of people with advanced kidney disease to nephrology services from both primary and secondary care is still at least as high as 30%, engendering increased mortality and morbidity and precluding assessment and preparation of those for whom conservative management is more appropriate.

Over 2% of the total NHS budget is spent on renal replacement therapy (dialysis and transplantation) for those with established renal failure. Strategies aimed at earlier identification and (where possible) prevention of progression to established renal failure are therefore clearly required. Equally importantly, population studies have shown that people with diagnosed chronic kidney disease (CKD) have a far greater likelihood of cardiovascular death than progression to established renal failure. Furthermore, the majority of people with CKD are asymptomatic and may not even be aware that they have any form of kidney problem.

The challenge is to: identify people with or at risk of developing CKD; determine who needs intervention to minimise cardiovascular risk and to determine what that intervention should comprise; determine who will develop progressive kidney disease and/or complications of kidney disease and how they may be identified and managed to reduce/prevent these outcomes; determine who needs referral for specialist kidney care. This requires adoption of an overall health approach and an integrated care strategy involving public awareness, professional education, policy influence, and improved care delivery systems all under-pinned by research.

Contents

• Guideline Development Group members
• Acknowledgements
• Preface
• Acronyms, abbreviations and glossary
• Development of the Guideline
  • 1. Introduction
    • 1.1 Background
    • 1.2 Definition
    • 1.3 Burden of disease
  • 2. Methodology
    • 2.1 Aim
    • 2.2 Scope
    • 2.3 Audience
    • 2.4 Involvement of people with CKD
    • 2.5 Guideline limitations
    • 2.6 Other work relevant to the guideline
    • 2.7 Background
    • 2.8 The process of guideline development
    • 2.9 Disclaimer
    • 2.10 Funding
  • 3. Key messages of the guideline
    • 3.1 Key priorities for implementation
    • 3.2 Algorithms
• The Guideline
  • 4. Investigation of CKD
    • 4.1 Measurement of kidney function
    • 4.2 Factors affecting the biological and analytical variability of GFR estimated from measurement of serum creatinine
    • 4.3 Detection of blood and protein in the urine
    • 4.4 Urinary albumin:creatinine and protein:creatinine ratios, and their relationship to 24-hour urinary protein
    • 4.5 Indications for renal ultrasound in the evaluation of CKD
  • 5. Classification and early identification
    • 5.1 The influence of GFR, age, gender, ethnicity and proteinuria on patient outcomes
    • 5.2 Who should be tested for CKD?
  • 6. Defining progression of CKD and the risk factors associated with progression
    • 6.1 Defining progression
    • 6.2 Risk factors associated with progression of CKD
  • 7. Referral criteria
    • 7.1 Indications for referral to specialist care
  • 8. Self management
    • 8.1 Modification of lifestyle
    • 8.2 Dietary intervention and renal outcomes
  • 9. Blood pressure control
    • 9.1 Blood pressure control in people with CKD
    • 9.2 Choice of anti-hypertensive agents for blood pressure control in people with CKD
    • 9.3 Practicalities of treatment with ACEI/ARBs in people with CKD
    • 9.4 Considerations of age in prescription of ACEI/ARB therapy
    • 9.5 The role of aldosterone antagonism in people with CKD
  • 10. Reducing cardiovascular disease
    • 10.1 Statin therapy and reduction in proteinuria
    • 10.2 Lipid lowering in people with CKD
    • 10.3 Antiplatelet therapy and anticoagulation in people with CKD
  • 11. Asymptomatic hyperuricaemia
    • 11.1 Asymptomatic hyperuricaemia in people with CKD
  • 12. Managing isolated invisible haematuria
    • 12.1 Isolated invisible (microscopic) haematuria
  • 13. Specific complications of CKD – renal bone disease
    • 13.1 Monitoring of calcium, phosphate, vitamin D and parathyroid hormone levels in people with CKD
    • 13.2 Risks and benefits of bisphosphonates for preventing osteoporosis in adults with CKD
    • 13.3 Vitamin D supplementation in people with CKD
  • 14. Specific complications of CKD – anaemia
    • 14.1 Anaemia identification in people with CKD
  • 15. Information needs
    • 15.1 Information, education and support for people with CKD and their carers
    • 15.2 Available tools to aid identification and maximise effectiveness of treatment and management of CKD
• References
• Appendices
  • Appendix A Evidence-based clinical questions and literature searches
  • Appendix B Scope of the guideline
  • Appendix C Health economic model – Cost effectiveness of CKD case finding among people at high risk
  • Appendix D GDG members’ declaration of interests
• Evidence Tables

Royal College of Physicians: The 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 Conditions: The 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.

Suggested citation:

National 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.