The National Institute for Health and Clinical Excellence (NICE) and the National Collaborating Centre for Chronic Conditions yesterday (24 September 2008) published a guideline which will help save lives of people with chronic kidney disease (CKD).

The guideline sets out how best to identify who has CKD; who is at risk of progression and at risk of serious complications, and how to manage their care.

CKD is a common condition encompassing problems such as abnormal kidney function or structure, with an estimated 3.4 million people in the UK having moderate or severe CKD. The majority of individuals with this condition do not experience any symptoms and therefore may be unaware that they have it, but there are simple tests which can detect the condition. If CKD remains undetected, it can progress to established kidney failure requiring dialysis or transplantation, very poor health and in some cases early death.

The guideline recommends offering simple blood and urine tests to individuals at risk of CKD to identify who has the disease as early as possible. This targeted, early identification of CKD will enable prompt advice and treatment, allowing most people to stay healthy. There are specific conditions which the guideline highlights as indicating a risk of CKD. For example, diabetes can damage the kidneys and therefore increases the risk of developing CKD.

The guideline also recommends that doctors provide individuals with high-quality information about the condition, and advises when to refer people already diagnosed with CKD to a specialist.

-- Health professionals should offer people testing for CKD if they have any of the following risk factors: diabetes; high blood pressure; cardiovascular disease; disease in the renal tract, kidney stones or an enlarged prostate; systemic diseases which may affect the kidneys; a family history of kidney failure; blood or protein in the urine discovered opportunistically

-- In the absence of the above risk factors, age, gender or ethnicity should not be used as markers to test people for CKD

-- Preferential use of the ACR1 test to identify low levels of protein in the urine indicative of chronic kidney disease, and use of ACR for people with diabetes

-- People should be offered an ultrasound scan in specified circumstances including worsening kidney function; blood in the urine; and family history of polycystic kidney disease

-- 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. Where any of the following apply, this includes people who: have cardiovascular disease; diabetes; are of African-Caribbean or Asian ethnicity; smoke; take long-term non-steroidal anti-inflammatory medicines (NSAIDs) which are often used for arthritis and other causes of chronic pain

-- People with CKD should be offered referral to a specialist in specified circumstances including renal failure or severe decrease in kidney function; high blood pressure despite using at least four medicines to control it; and urinary tract obstruction.

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."

Dr Donal O'Donoghue, National Director of Kidney Care welcomed the NICE guideline saying: "Chronic kidney disease is a potentially dangerous condition, affecting more than 1 in 10 people. People with kidney disease have few or no symptoms until the kidney function is severely impaired, and if it's not recognised, people with the condition may have up to 35 times higher risk of premature death. It's very easy to detect kidney disease in the early stages with a simple blood test and a urine test for albumin/protein. This NICE guideline on kidney disease will help healthcare professionals identify people in the early stages who can then be treated - it thus has the potential to delay progression of disease and extend the lives of thousands of people."

Dr David Halpin, Chair of the Guideline Development Group, said: "There are people in the community who don't know they have chronic kidney disease - this new NICE guideline will help us to target their identification so we can offer them the best care, management and treatment. Early action is essential in helping individuals maintain healthy lives. For people who already know that their kidneys don't work properly but are stable, the guideline provides reassurance that any changes in their condition can be carefully monitored to reduce chance of disease progression. It also highlights that being of African-Caribbean or Asian ethnicity, a smoker, or having a urinary tract obstruction are some of the factors indicating kidney disease is more likely to worsen, so health professionals can give appropriate advice and close monitoring. This guideline sets standards for the best ways to detect and prevent the progression of chronic kidney disease, thus helping to end the existing variation in practice and improving standards of care for patients."

Dr Paul Stevens, Clinical Advisor to the Guideline Development Group and Consultant Nephrologist, said: "The good news is that early identification of CKD and appropriate management or treatment can potentially lead to prevention, or at the very least, reducing disease progression and allow individuals to maintain their health. Everyone at risk of having chronic kidney disease will benefit from this consistent national approach to picking up people with the condition at an early stage and providing appropriate care. One important issue though is to avoid labeling people as having a condition when they only have a risk factor linked to CKD. This guideline will help improve this situation by giving recommendations based on the best available evidence on tests to measure kidney function, monitor progression and criteria for specialist referral. The guideline also highlights that ongoing care for people with CKD can be provided by a range of professionals such as GPs, geriatricians and nurses once a patient has been seen by a specialist team and a care plan is agreed."

Caroline Forrest, Practice Nurse and Guideline Development Group member says: "An estimated 3.4 million people in the UK have moderate or severe chronic kidney disease. It's vital to identify further individuals who may be totally unaware that they also have the condition so that they can be offered advice on managing the condition or treatment. Nurses and doctors in primary care have an important role in identifying people who have a higher risk of CKD, and in advising new and existing patients of lifestyle changes to reduce chances of the condition progressing. This guideline will help create greater awareness of the condition amongst healthcare professionals and the public, so that more people with risk factors can be checked for possible CKD and get the support they need. "

Miranda Dodwell, Consumer Representative and Guideline Development Group member says: "This NICE guideline is welcome news for people with chronic kidney disease, and for people with a risk of developing the condition. Factors like a family history of serious kidney disease, such as dialysis or kidney transplant, or conditions like diabetes, can help indicate those at higher risk of having CKD. By identifying CKD as early as possible, people with the condition can benefit from appropriate medical advice and treatment. They also need to have access to high quality information to help them make decisions about their treatment. This guideline will give people with CKD the opportunity to make changes to their lifestyle at an early stage to help them to maintain their health. In particular, people with CKD are encouraged to exercise regularly, achieve a healthy weight and stop smoking."

The guidance is available at nice/CG73.

1 To detect and identify protein in the urine which is an early marker of CKD, ACR (the urine albumin:creatinine ratio) is recommended in preference as it is more sensitive than PCR (protein:creatinine ratio) for low levels of protein in the urine.

About NICE

The National Institute for Health and Clinical Excellence (NICE) is the independent organisation responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health.

NICE produces guidance in three areas of health:

public health - guidance on the promotion of good health and the prevention of ill health for those working in the NHS, local authorities and the wider public and voluntary sector
health technologies - guidance on the use of new and existing medicines, treatments and procedures within the NHS
clinical practice - guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS.


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