NICE summary

The recommendations in this Best Practice topic are based on authoritative international guidelines, supplemented by recent practice-changing evidence and expert opinion. For your added benefit, we summarise below the key recommendations from relevant NICE guidelines.

Key NICE recommendations on diagnosis

This summary covers chronic kidney disease (CKD) in adults.

Offer testing for CKD using eGFRcreatinine (glomerular filtration rate [GFR] estimated using serum creatinine) and albumin:creatinine ratio (ACR) to adults with any of the following risk factors:

  • Diabetes

  • Hypertension

  • Previous episode of acute kidney injury (AKI)

    • Monitor people for the development or progression of CKD for at least 3 years after AKI (longer if AKI stage 3) even if estimated GFR (eGFR) has returned to baseline

  • Cardiovascular disease (ischaemic heart disease, chronic heart failure, peripheral vascular disease or cerebral vascular disease)

  • Structural renal tract disease, recurrent renal calculi or prostatic hypertrophy

  • Multisystem diseases with potential kidney involvement (e.g., systemic lupus erythematosus)

  • Gout

  • Family history of end-stage renal disease or hereditary kidney disease

  • Incidental detection of haematuria or proteinuria (e.g., on a reagent strip).

    Advise the person not to eat any meat in the 12 hours before having a blood test for eGFRcreatinine.

Do not use any of the following as risk factors indicating testing for CKD: age, gender, ethnicity, or obesity (in the absence of metabolic syndrome, diabetes or hypertension).

If eGFR is >90 ml/min/1.73 m², use an increase in serum creatinine concentration of >20% to infer significant reduction in kidney function.

If eGFR is <60 ml/min/1.73 m² in an adult not previously tested, repeat the test within 2 weeks to confirm the result.

Be aware that eGFRcreatinine may be less reliable in certain situations. See the NICE guideline for more information about interpreting GFR values.

Measure proteinuria and test for haematuria in the following groups:

  • Adults with diabetes (type 1 or type 2)

  • Adults with an eGFR of <60 ml/min/1.73 m²

  • Adults with an eGFR of ≥60 ml/min/1.73 m² if there is a strong suspicion of CKD.

For initial detection of proteinuria, use urine ACR. Do not use reagent strips unless they can specifically measure albumin at low concentrations and give an ACR result. If initial ACR is:

  • Between 3 mg/mmol and 70 mg/mmol – check ACR in a subsequent early morning sample to confirm the result

    • Regard a confirmed ACR of ≥3 mg/mmol as clinically important proteinuria

  • ≥70 mg/mmol – a repeat sample is not needed.

    • If ACR is ≥70 mg/mmol, protein:creatinine ratio (PCR) can be used as an alternative to ACR.

Use reagent strips to test for haematuria and evaluate further for results of 1+ or higher. Do not use urine microscopy to confirm a positive result.

  • Regard 2 out of 3 positive reagent strips as confirmation of persistent (rather than transient) invisible haematuria, which (with or without proteinuria) should prompt investigation for urinary tract malignancy in appropriate age groups, in line with the NICE guideline Suspected cancer: recognition and referral (NG12).

  • Persistent invisible haematuria without proteinuria should be followed up annually with repeat testing for haematuria, proteinuria or albuminuria, GFR and blood pressure monitoring as long as the haematuria persists.

Diagnose CKD if abnormalities of kidney function or structure are present for >3 months. This includes:

  • People with a GFR of <60 ml/min/1.73 m² on at least 2 occasions separated by a period of at least 90 days (with or without markers of kidney damage)

  • All people with markers of kidney damage (e.g., albuminuria [ACR >3 mg/mmol], urine sediment abnormalities, electrolyte and other abnormalities due to tubular disorders, abnormalities detected by histology, structural abnormalities detected by imaging, history of kidney transplantation).

Monitor GFR at least annually in people taking medicines that can adversely affect kidney function (e.g., lithium, calcineurin inhibitors [e.g., ciclosporin, tacrolimus], long-term chronic use of non-steroidal anti-inflammatory drugs [NSAIDs]).

Classification of CKD and investigation of the cause

See the NICE guideline for how to classify CKD in adults using a combination of GFR and ACR categories, and use this to indicate the person’s risk of adverse outcomes (e.g., CKD progression, AKI, all-cause mortality and cardiovascular events), discussing this with them.

  • Increased ACR and decreased GFR are associated with increased risk of adverse outcomes. Presence of both in combination multiplies the risk of adverse outcomes.

Agree a plan to establish the cause of CKD, particularly if the cause may be treatable (e.g., urinary tract obstruction, glomerular disease).

Offer a renal ultrasound scan to all adults with CKD who have any of the following:

  • Accelerated progression of CKD (i.e., sustained decrease in GFR of ≥25% and a change in GFR category within 12 months or a sustained decrease in GFR of 15 ml/min/1.73 m² per year)

  • Visible or persistent invisible haematuria

  • Symptoms of urinary tract obstruction

  • Family history of polycystic kidney disease and are older than 20

  • GFR of <30 ml/min/1.73 m²

  • A need for renal biopsy (as considered by a nephrologist).

Advise adults with a family history of hereditary kidney disease about the implications of an abnormal result before a renal ultrasound scan is arranged.

Links to NICE guidance

Chronic kidney disease: assessment and management (NG203) November 2021. https://www.nice.org.uk/guidance/ng203

Key NICE recommendations on management

Refer to the full NICE guideline and your local drug formulary for further information when prescribing – including dose, contraindications, cautions, safety issues, adverse effects, drug interactions, and monitoring requirements. Please be aware that some of the following indications for medications may not be licensed by the manufacturer (i.e., the use of the medication is 'off-label').

Do not determine management of CKD solely by age.

Offer people with CKD education and information tailored to the severity and cause of CKD, the associated complications and the risk of progression. Include information about their 5-year risk of needing renal replacement therapy (measured using the 4-variable Kidney Failure Risk Equation), appropriate lifestyle advice, and consider the need for psychological support. See the NICE guideline for more information on advice to give to people with CKD.

Optimise the health of adults with any of the following risk factors for CKD progression:

  • Cardiovascular disease

  • Proteinuria

  • Previous episode of AKI

  • Hypertension

  • Diabetes

  • Smoking

  • African, African-Caribbean or Asian family origin

  • Chronic use of NSAIDs

    • Exercise caution when giving NSAIDs to people with CKD over prolonged periods of time. Monitor the effects on GFR, particularly in people with a low baseline GFR and/or in the presence of other risks for progression. Also note that acute use of NSAIDs is associated with a reversible decrease in GFR.

  • Untreated urinary outflow tract obstruction.

Referral

Refer adults with CKD for specialist assessment (taking into account their wishes and comorbidities) if they have any of the following:

  • 5-year risk of needing renal replacement therapy >5%

  • ACR ≥70 mg/mmol, unless known to be caused by diabetes and already appropriately treated (see Pharmacotherapy: treating persistent proteinuria below)

  • ACR >30 mg/mmol, together with haematuria

  • Sustained decrease in eGFR of ≥25% and a change in eGFR category within 12 months

  • Sustained decrease in eGFR of ≥15 ml/min/1.73 m² per year

  • Hypertension that remains poorly controlled (above the person's individual target) despite the use of at least 4 antihypertensive medicines at therapeutic doses

  • Known or suspected rare or genetic causes of CKD

  • Suspected renal artery stenosis

  • Renal outflow obstruction: refer to urological services, unless urgent treatment is needed (e.g., for hyperkalaemia, severe uraemia, acidosis or fluid overload).

Consider discussing management with a specialist if there are concerns but the person with CKD does not need to see a specialist.

Pharmacotherapy: treating hypertension

In adults with CKD (using clinical judgement for people with frailty or multimorbidity):

  • If ACR is <70 mg/mmol: aim for a clinic systolic blood pressure <140 mmHg (target range 120 to 139 mmHg) and a clinic diastolic blood pressure <90 mmHg

  • If ACR is ≥70 mg/mmol: aim for a clinic systolic blood pressure <130 mmHg (target range 120 to 129 mmHg) and a clinic diastolic blood pressure <80 mmHg.

Follow the recommendations on treating hypertension in the NICE guideline Hypertension in adults: diagnosis and management (NG136) for adults with CKD, hypertension and an ACR ≤30 mg/mmol.

Offer an angiotensin-II receptor antagonist or an ACE inhibitor to people with CKD who have hypertension and an ACR >30 mg/mmol.

Pharmacotherapy: treating persistent proteinuria

For adults with CKD and diabetes (type 1 or type 2) offer an angiotensin-II receptor antagonist or an ACE inhibitor if ACR is ≥3 mg/mmol.

For adults with CKD without diabetes, if ACR is:

  • ≥70 mg/mmol: refer for nephrology assessment and offer an angiotensin-II receptor antagonist or an ACE inhibitor

  • >30 but <70 mg/mmol: monitor and consider discussing with a nephrologist if eGFR declines or ACR increases.

Do not offer a combination of renin–angiotensin system antagonists.

Dapagliflozin and empagliflozin (sodium-glucose cotransporter-2 [SGLT2] inhibitors) are recommended as options for some adults with CKD as an add-on to optimised standard care. See the NICE guideline for more information on sodium-glucose cotransporter-2 (SGLT2) inhibitors.

Finerenone is recommended as an option for some adults with stage 3 and 4 CKD (with ACR ≥3 mg/mmol) associated with type 2 diabetes as an add-on to optimised standard care.

When offering medicines to lower proteinuria to people with frailty, comorbidities or who are taking many other prescribed medicines, seek specialist advice if needed.

Pharmacotherapy: other

See the NICE guideline Cardiovascular disease: risk assessment and reduction, including lipid modification (CG181) for recommendations on the use of statins in adults with CKD.

Offer antiplatelet medicines to adults with CKD for the secondary prevention of cardiovascular disease, but be aware of the increased risk of bleeding.

Monitoring

If a person has CKD, or is at risk, agree the frequency of monitoring (eGFRcreatinine and ACR) with them, bearing in mind that CKD is not progressive in many people. See the NICE guideline for more information on how to determine frequency of monitoring.

Take the following steps to identify the rate of progression of CKD:

  • Obtain a minimum of 3 GFR estimations over a period of not less than 90 days

  • In adults with a new finding of reduced GFR, repeat the GFR within 2 weeks to exclude causes of acute deterioration of GFR (e.g., AKI, or starting renin–angiotensin system antagonist therapy [e.g., ACE inhibitors, angiotensin-II receptor antagonists and direct renin inhibitors]).

Adults with CKD are at increased risk of progression to end-stage renal disease if they have a sustained decrease in GFR of:

  • ≥25% over 12 monthsor

  • ≥15 ml/min/1.73 m² over 12 months.

When assessing CKD progression, extrapolate the current rate of decline of GFR and take this into account when planning intervention strategies, particularly if it suggests that the person might need renal replacement therapy in their lifetime.

Be aware of the following complications of CKD (and see the NICE guideline for detailed assessment and management of such complications):

  • Anaemia

    • Consider investigating and managing anaemia if the person’s haemoglobin level falls to ≤110 g/litre or they develop symptoms attributable to anaemia (e.g., tiredness, shortness of breath, lethargy, palpitations)

  • CKD–mineral and bone disorder

    • Measure serum calcium, phosphate and parathyroid hormone concentrations in adults with a GFR of <30 ml/min/1.73 m². Determine the subsequent frequency of testing by the measured values and the clinical circumstances. If doubt exists, seek specialist opinion

    • Do not routinely measure calcium, phosphate, parathyroid hormone and vitamin D levels in adults with a GFR of ≥30 ml/min/1.73 m²

  • Metabolic acidosis.

© NICE (2021) All rights reserved. Subject to Notice of rights NICE guidance is prepared for the National Health Service in England https://www.nice.org.uk/terms-and-conditions#notice-of-rights. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.

Links to NICE guidance

Chronic kidney disease: assessment and management (NG203) November 2021. https://www.nice.org.uk/guidance/ng203

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