About this guideline

NICE clinical guidelines are recommendations about the treatment and care of people with specific diseases and conditions.

NICE guidelines are developed in accordance with a scope that defines what the guideline will and will not cover.

This guideline was developed by the National Clinical Guideline Centre. The Centre worked with a Guideline Development Group, comprising healthcare professionals (including consultants, GPs and nurses), patients and carers, and technical staff, which reviewed the evidence and drafted the recommendations. The recommendations were finalised after public consultation.

The methods and processes for developing NICE clinical guidelines are described in the guidelines manual.

NICE produces guidance, standards and information on commissioning and providing high‑quality healthcare, social care, and public health services. We have agreements to provide certain NICE services to Wales, Scotland and Northern Ireland. Decisions on how NICE guidance and other products apply in those countries are made by ministers in the Welsh government, Scottish government, and Northern Ireland Executive. NICE guidance or other products may include references to organisations or people responsible for commissioning or providing care that may be relevant only to England.

Update information

This guideline updates and replaces NICE guideline CG114 (published February 2011).

Recommendations are marked as [new 2015], [2011], [2006], [2011, amended 2015] or [2006, amended 2015]:

  • [new 2015] indicates that the evidence has been reviewed and the recommendation has been added or updated

  • [2011] indicates that the evidence has not been reviewed since 2011

  • [2006] indicates that the evidence has not been reviewed since 2006

  • [2006, amended 2015] indicates that the evidence has not been reviewed since 2006, but changes have been made to the recommendation wording that change the meaning (see below)

  • [2011, amended 2015] indicates that the evidence has not been reviewed since 2011, but changes have been made to the recommendation wording that change the meaning (see below)

Recommendations from NICE guideline CG114 that have been amended

Recommendations are labelled [2006, amended 2015] or [2011, amended 2015] if the evidence has not been reviewed but changes have been made to the recommendation wording that change the meaning.

Recommendation in 2011 guideline

Recommendation in current guideline

Reason for change

In people with anaemia of CKD, there may be situations where a transfusion is indicated clinically. In these cases, the relevant haematology guidelines should be followed[a]. [2006] (1.3.2.2)

In people with anaemia of CKD, there may be situations where a transfusion is indicated clinically. In these cases, follow the relevant national guidance[b]. [2006, amended 2015] (1.3.3)

The reference has been removed as this evidence has not been reviewed by NICE.

The NICE guideline on blood transfusion is currently in development and will form the basis of relevant haematology guidance in this area. This guideline is expected to publish in November 2015.

The correction to normal levels of Hb with ESAs is not usually recommended in people with anaemia of CKD.

• Typically maintain the aspirational Hb range between 10 and 12 g/dl for adults, young people and children aged 2 years and older, and between 9.5 and 11.5 g/dl for children younger than 2 years of age, reflecting the lower normal range in that age group.

• To keep the Hb level within the aspirational range, do not wait until Hb levels are outside the aspirational range before adjusting treatment (for example, take action when Hb levels are within 0.5 g/dl of the range's limits). [new 2011] (1.3.8.2)

The correction to normal levels of Hb with ESAs is not usually recommended in people with anaemia of CKD.

• Typically[c] maintain the aspirational Hb range between 100 and 120 g/litre for adults, young people and children aged 2 years and older, and between 95 and 115 g/litre for children younger than 2 years of age, reflecting the lower normal range in that age group.

• To keep the Hb level within the aspirational range, do not wait until Hb levels are outside the aspirational range before adjusting treatment (for example, take action when Hb levels are within 5 g/litre of the range's limits). [2011, amended 2015] (1.3.11)

The footnote was added because it was decided to be more cautious given the findings of the review and the guidance from the Medicines and Health Regulatory Agency with regard to the increased risk of mortality and cardiovascular morbidity associated with higher levels of haemoglobin.

Routine monitoring of iron stores should be at intervals of 4 weeks to 3 months. [2006] (1.4.1.2)

Routine monitoring of iron stores to prevent iron overload using serum ferritin should be at intervals of 1–3 months. [2006, amended 2015] (1.4.2)

Based on new evidence, serum ferritin is now recommended for assessment of iron overload only and not for diagnosis of iron deficiency. This recommendation has been amended to reflect this new evidence base. The frequency of monitoring is also covered elsewhere (see recommendation 1.3.19).

[a] Chapman JF, Elliott C, Knowles SM et al. (2004) Guidelines for compatibility procedures in blood transfusion laboratories. Transfusion Medicine 14(1): 59–73.

[b] NICE is developing the guideline 'Blood transfusion' (publication expected November 2015).

[c] The Medicines and Healthcare products Regulatory Agency (MHRA) guidance (2007) notes that using ESAs to achieve Hb levels greater than 120 g/litre is associated with an increased risk of death and serious cardiovascular events in people with CKD. The MHRA advises that Hb levels greater than this should be avoided, and that patients should be monitored closely to ensure that the lowest approved dose of ESA is used to provide adequate control of the symptoms of anaemia. Use of ESAs to achieve Hb levels greater than 120 g/litre is not consistent with UK marketing authorisations for ESAs. If such use is considered, the prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information.

Strength of recommendations

Some recommendations can be made with more certainty than others. The Guideline Development Group makes a recommendation based on the trade‑off between the benefits and harms of an intervention, taking into account the quality of the underpinning evidence. For some interventions, the Guideline Development Group is confident that, given the information it has looked at, most patients would choose the intervention. The wording used in the recommendations in this guideline denotes the certainty with which the recommendation is made (the strength of the recommendation).

For all recommendations, NICE expects that there is discussion with the patient about the risks and benefits of the interventions, and their values and preferences. This discussion aims to help them to reach a fully informed decision (see also patient-centred care).

Interventions that must (or must not) be used

We usually use 'must' or 'must not' only if there is a legal duty to apply the recommendation. Occasionally we use 'must' (or 'must not') if the consequences of not following the recommendation could be extremely serious or potentially life threatening.

Interventions that should (or should not) be used – a 'strong' recommendation

We use 'offer' (and similar words such as 'refer' or 'advise') when we are confident that, for the vast majority of patients, an intervention will do more good than harm, and be cost effective. We use similar forms of words (for example, 'Do not offer…') when we are confident that an intervention will not be of benefit for most patients.

Interventions that could be used

We use 'consider' when we are confident that an intervention will do more good than harm for most patients, and be cost effective, but other options may be similarly cost effective. The choice of intervention, and whether or not to have the intervention at all, is more likely to depend on the patient's values and preferences than for a strong recommendation, and so the healthcare professional should spend more time considering and discussing the options with the patient.

Recommendation wording in guideline updates

NICE began using this approach to denote the strength of recommendations in guidelines that started development after publication of the 2009 version of 'The guidelines manual' (January 2009). This does not apply to any recommendations ending [2006] (see update information above for details about how recommendations are labelled). In particular, for recommendations labelled [2006] the word 'consider' may not necessarily be used to denote the strength of the recommendation.

Other versions of this guideline

The full guideline, anaemia management in chronic kidney disease contains details of the methods and evidence used to develop the guideline. It is published by the National Clinical Guideline Centre.

The recommendations from this guideline have been incorporated into a NICE pathway.

We have produced information for the public about this guideline.

Implementation

Implementation tools and resources to help you put the guideline into practice are also available.

ISBN: 978-1-4731-1149-3

  • National Institute for Health and Care Excellence (NICE)