NICE issues guidelines for chronic kidney disease- early identification and management
Sep 27, 2008 - 8:17:35 AM

The new National Institute for Health and Clinical Excellence (NICE) guidelines for the management of early kidney disease were issued on the 24th of September 2008. It focuses on the early identification of renal disease in high risk individuals (i.e. in patients with diabetes mellitus, hypertension, multisystem disorders, cardiovascular disease and those with family history of kidney disease), management of risk factors and early kidney disease and appropriate referral for specialist care.

Dr Gillian Leng, NICE Deputy Chief Executive, and Executive Lead for this guideline said: "Chronic kidney disease often has no symptoms so can go undetected, potentially leading to serious health problems. This new guideline will help save lives and prevent ill-health by advising how to identify people at risk of CKD at an early stage. The guideline recommends offering people a simple test for CKD if they have risk factors like diabetes, high blood pressure, cardiovascular disease and a family history of kidney failure. This will ensure that they get advice and treatment as quickly as possible, which in most cases will allow them to stay healthy."

There has been an emphasis placed on using urine albumin–creatinine ratio (ACR) for detecting proteinuria as it is more sensitive than a protein–creatinine ratio. Subsequently, physicians may choose to quantify or follow up proteinuria with PCR monitoring. ACR is the preferred method in patients with diabetes.

A lot of emphasis has been placed on the monitoring of the GFR (glomerular filtration rate). Stages of chronic kidney disease has been updated to the following

Stage GFR (ml/min/1.73m2) Description
1 ≥ 90 Normal or increased 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 GFR, with or without other evidence of kidney damage
3B 30–44
4 15–29 Severe decrease in GFR, with or without other evidence of kidney damage
5 < 15 Established renal failure
Use the suffix (p) to denote the presence of proteinuria when staging CKD

Particularly useful is the section which deals with criteria for referral to a nephrologist. It is recommended that the following groups of patients be refered to the specialist.
1)stage 4 and 5 CKD (with or without diabetes)
2)higher levels of proteinuria (ACR 70 mg/mmol or more, approximately equivalent to PCR 100 mg/mmol or more, or urinary protein excretion 1 g/24 h or more) unless known to be due to diabetes and already appropriately treated
3)proteinuria (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) together with haematuria
4) rapidly declining eGFR (more than 5 ml/min/1.73 m2 in 1 year, or more than 10 ml/min/1.73 m2 within 5 years)
5) hypertension that remains poorly controlled despite the use of at least four antihypertensive drugs at therapeutic doses
6)people with, or suspected of having, rare or genetic causes of CKD
7)suspected renal artery stenosis.
Furthermore patients with chronic kidney disease and renal outflow obstruction should normally be referred to urological services.

Lifestyle advice and patient education has been dealt with. Health professionals should work with people who are more likely to have progressive kidney disease to maintain the best possible health, and check their kidney function regularly. This includes people who: have cardiovascular disease, diabetes, proteinuria,are of African-Caribbean or Asian ethnicity; smoke; take long-term non-steroidal anti-inflammatory medicines or have chronic urinary tract obstruction. Blood pressure targets are to keep the systolic pressure below 140 mm Hg and diastolic pressure below 90 mm Hg for patients with CKD in keeping with previous NICE hypertension guidelines. Blood pressure targets for CKD patients with diabetes mellitus or patients with ACR equal to or greater than 70 mg/mmol are to keep the systolic pressure below 130 mm Hg and diastolic pressure below 80 mm Hg. ACE inhibitors and ARBs should be the first choice of antihypertensives for patients with CKD and diabetes or ACR of 70 mg/mmol or more. Statin use and treatment of renal bone disease has been covered for early kidney disease. Treatment of anaemia has not been covered as there is a separate NICE guideline for that.

Finally it is worth noting that it does not cover patient with end stage renal disease on renal replacement therapy, renal dysfunction in pregnant women, short lasting renal dysfunction or renal disease in children under 16 years of age.

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