Surveillance decision

Surveillance decision

Following the joint surveillance review of the guidelines on hyperphosphataemia in chronic kidney disease, chronic kidney disease in adults and chronic kidney disease: managing anaemia, it is proposed that consideration be given to combining the 3 guidelines to ensure that recommendations on the management of chronic kidney disease are accessible from 1 clinical guideline.

We will plan an update of the guideline on hyperphosphataemia in chronic kidney disease. The update will focus on:

  • Cost effectiveness of phosphate binders for children, young people and adults with chronic kidney disease (CKD) stages 4–5, both on dialysis and not on dialysis.

We will plan an update of the guideline on chronic kidney disease in adults. The update will focus on:

  • Investigations for and classification of chronic kidney disease:

    • the use of the Tangri score in predicting the risk of progression to end stage renal disease (ESRD) in CKD patients.

  • Defining progression:

    • The value of lesser declines in estimated glomerular filtration rate (eGFR) over a longer period than 1 year in identifying CKD patients at increased risk of progression.

  • Anaemia identification in people with CKD (see update of the guideline on chronic kidney disease: managing anaemia below, which will be cross referred to).

We will plan an update of the guideline on chronic kidney disease: managing anaemia. The update will focus on:

  • Diagnostic role of glomerular filtration rate:

    • The trigger threshold of the eGFR for investigation of anaemia being due to CKD (a cross-referral will be added to this update from the guideline on chronic kidney disease in adults).

During surveillance editorial or factual corrections were identified for the guideline on chronic kidney disease: managing anaemia.

Details are included in appendix A3: summary of evidence from surveillance for the guideline on chronic kidney disease: managing anaemia.

Reason for the decision

Assessing the evidence

We found 162 studies through surveillance: 23 studies for the guideline on hyperphosphataemia in chronic kidney disease, 105 studies for the guideline on chronic kidney disease in adults and 34 studies for the guideline on chronic kidney disease: managing anaemia.

Evidence that could affect recommendations was identified. Topic experts, including those who helped to develop the guidelines, advised us about whether the following sections of the guidelines should be updated:

Hyperphosphataemia in chronic kidney disease

  • For people with stage 4 or 5 CKD who are not on dialysis, are phosphate binders effective compared with placebo or other treatments in managing serum phosphate and its associated outcomes?

  • For people with stage 5 CKD who are on dialysis, are phosphate binders effective compared to placebo or other treatments in managing serum phosphate and its associated outcomes?

Topic expert feedback indicated that sevelamer carbonate is available at a considerably reduced cost to hydrochloride as a generic version. Therefore the majority of topic experts highlighted a need to revise the health economic modelling, and to consider the carbonate version that was not included in the development of the guideline. Topic experts also agreed that:

  • Practice relating to the use of combinations of phosphate binders had not changed sufficiently to justify inclusion in the economic model.

  • They were unaware of any new evidence to inform cost effectiveness analysis for people with stage 4 or 5 CKD that are not on dialysis.

  • The approach taken during the guideline development of adapting evidence from people with stage 5 CKD to those with stage 4 or 5 CKD remains an acceptable approach for the revised model.

  • The limited evidence base on the effectiveness of phosphate binders in children has not changed since the guideline was developed.

Decision: These review questions should be updated.

Chronic kidney disease in adults

Investigations for chronic kidney disease
  • What is the best combination of measures of kidney function and markers of kidney damage to identify people with CKD who are at increased risk of progression?

Classification of chronic kidney disease
  • For people with suspected CKD, what is the effect of proteinuria at any given eGFR on adverse outcomes?

Topic expert feedback indicated that the Tangri score is accurate in predicting end stage renal disease (ESRD) with high discrimination. It was considered by the majority of topic experts to have a role in patient decision making and prognostication. Experts also felt that it could affect the referral pathway from primary to secondary care, with more timely access to dialysis due to better risk stratification. Patients could potentially be triaged using the Tangri score for intensive management versus discharge back to GP.

However, the Tangri score only predicts the risk of progressive CKD, but does not predict the additional risks of cardiovascular disease or related death. It was also highlighted that in primary care it is equally important to identify people at low risk of CKD progression but in whom acute conditions, such as episodes of kidney injury or cardiovascular events, could increase the level of risk. It was agreed that these factors will need to be considered during the update process.

The majority of topic experts also agreed that the two relevant review questions should be reviewed together in terms of the impact of the Tangri score. However, they advised caution to avoid confusing the recommendations relating to investigation and classification of CKD.

Decision: These review questions should be updated.

Frequency of monitoring
  • In people with CKD, what constitutes a clinically significant decline in eGFR?

Topic expert feedback indicated that the standard annual review in clinical practice fits with a 1-year follow up, as recommended in chronic kidney disease in adults: assessment and management (NICE guideline CG182), as distinct from a 2- or 3-year follow up. However, as CKD is a long term condition, definitions of progression that are easy to use in practice over a longer time period are needed.

The finding that that a 30% change over 2 years is associated with a 5-fold increase in risk of ESRD was noted by experts to be a very significant new finding. It was considered to have the capability of identifying patients at high risk of ESRD who are likely to benefit from earlier referral, who will not be highlighted as such currently. Consequently it may result in a significant change in practice.

Further expert feedback highlighted a limitation of the guideline, which risks missing patients who decline by successive increments just below the currently recommended annual threshold. These patients could benefit from specialist review. A review of the current description of accelerated progression, which uses comparison of annual blood tests rather than trends over longer periods, was also suggested.

Additional topic expert feedback indicated that:

  • The rate of decline should be 30% over 2 years to a threshold of less than 60 ml/min/1.73 ml2, as distinct from 100 to 70 ml/min/1.73 ml2, as even the CKD Epidemiology Collaboration (CKD‑EPI) creatine equation has considerable imprecision above a GFR of 60 ml/min/1.73 ml2.

  • The smaller the rate of decline that is set to define progression the higher the sensitivity and the lower the specificity. The imprecision arises from the non-linear nature of CKD progression and the impact of related events, such as acute kidney injury.

  • A rate of decline over a longer period may also affect other health parameters aside from CKD progression, such as cardiovascular complications and morbidity. It was suggested that incorporating a revised rate of decline into the guideline could complement the use of the Tangri score.

Decision: This review question should be updated.

Other complications
  • Anaemia identification in people with CKD.

The recommendation in this area cross refers to the guideline on chronic kidney disease: managing anaemia. See below for details of the update.

Decision: This review question should be updated.

We also found evidence on the accuracy of equations to estimate glomerular filtration rate (GFR), information and education, and on referral criteria that supports current recommendations.

We found evidence on treatment for mild hyperkalaemia and on complementary therapies, which was not covered in the guideline. However, the evidence was insufficient to add new recommendations in these areas at this time.

Chronic kidney disease: managing anaemia

Diagnostic evaluation and assessment of anaemia
  • Diagnostic role of glomerular filtration rate.

In developing the guideline on chronic kidney disease: managing anaemia, the guideline committee retained the previous 2006 recommendation for the trigger threshold of the eGFR for investigation of anaemia being due to CKD. Currently this is recommended to be below 60 ml/min/1.73 ml2, although the rationale for this was consensus-based.

The majority of experts that contributed to the surveillance review agreed that a threshold below 60 ml/min/1.73 ml2 was too high, did not reflect current practice and was out of date. The preferred threshold was agreed by the majority of experts to be less than 30 ml/min/1.73 ml2 in current clinical practice today.

Some topic expert feedback indicated that separate thresholds may be required for people with CKD with and without diabetes. A threshold of less than 45 ml/min/1.73 ml2 was suggested for people with diabetes. However, additional topic expert feedback indicated that people with diabetes may nonetheless benefit from some investigation if they develop anaemia above a threshold of 30 ml/min/1.73 ml2 and that this occurs in practice. The use of a single threshold for all people could also avoid over-complication in clinical practice.

Decision: This review question should be updated.

We also found evidence on managing anaemia and on assessment and optimisation of erythropoiesis that supports current recommendations.

Equalities

We identified no equalities issues during the surveillance process.

Overall decision

After considering all the evidence and views of topic experts, we decided that a partial update is necessary for all three guidelines.

See how we made the decision for further information.


This page was last updated: 24 April 2017