WIREDGOV

The National Institute for Health and Clinical Excellence (NICE) and the National
Collaborating Centre for Chronic Conditions today (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.

Key recommendations from the guideline include:

• 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 labelling
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.”

Notes to Editors

About the guideline

About NICE

1. 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.

2. 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