Quality statement 1: Identification and monitoring

Quality statement

Adults with, or at risk of, chronic kidney disease (CKD) have eGFRcreatinine and albumin:creatinine ratio (ACR) testing at the frequency agreed with their healthcare professional. [2011, updated 2017]

Rationale

Routine monitoring of key markers of kidney function for adults with, or at risk of, CKD will enable earlier diagnosis and early action to reduce the risks of CKD progression, such as cardiovascular disease, end-stage kidney disease and mortality.

Quality measures

Structure

Evidence of local systems that invite adults with, or at risk of, CKD to have eGFRcreatinine and ACR testing.

Data source: Local data collection, for example, through local protocols on appointment reminders.

Process

a) Proportion of adults with CKD who had eGFRcreatinine testing in the past year.

Numerator – the number in the denominator who had eGFRcreatinine testing in the past year.

Denominator – the number of adults with CKD.

Data source: Local data collection, for example, audit of health records. The National CKD Audit reports the percentage of people with coded CKD stages 3 to 5 with a repeat blood test of their kidney function in the past year.

b) Proportion of adults with CKD who had ACR testing at the frequency agreed with their healthcare professional.

Numerator – the number in the denominator who had ACR testing at the frequency agreed with their healthcare professional.

Denominator – the number of adults with CKD.

Data source: Local data collection, for example, audit of health records. The National CKD Audit reports the percentage of people with coded CKD stages 3 to 5 who had an ACR urinary test result in the previous year.

c) Proportion of adults at risk of CKD who had eGFRcreatinine testing at the frequency agreed with their healthcare professional.

Numerator – the number in the denominator who had eGFRcreatinine testing at the frequency agreed with their healthcare professional.

Denominator – the number of adults at risk of CKD.

Data source: Local data collection, for example, audit of health records. The National CKD Audit reports the percentage of people with diabetes tested using serum creatinine in the past year, and people at risk of CKD without diabetes tested in the past 5 years.

d) Proportion of adults at risk of CKD who had ACR testing at the frequency agreed with their healthcare professional.

Numerator – the number in the denominator who had ACR testing at the agreed frequency.

Denominator – the number of adults at risk of CKD.

Data source: Local data collection, for example, audit of health records. The National CKD Audit reports the percentage of people with diabetes tested using ACR in the past year, and people at risk of CKD without diabetes tested in the past 5 years.

Outcomes

a) Prevalence of undiagnosed CKD.

Data source: NHS Digital's Quality and Outcomes Framework 2015–16 reports the prevalence of patients aged 18 or over with CKD with classification of categories G3a to G5 registered at GP practices. Comparing recorded prevalence with expected prevalence estimated using a tool, such as Public Health England's CKD prevalence model, can give an indication of local prevalence of undiagnosed CKD.

b) Stage of CKD at diagnosis.

Data source: Local data collection, for example, audit of health records.

What the quality statement means for different audiences

Service providers (general practices and secondary care services, such as renal, cardiology, diabetes and rheumatology clinics) ensure that systems are in place to identify adults with, or at risk of, CKD, for example through computerised or manual searching of medical records, and offer an appointment to discuss with them how frequently they should have eGFRcreatinine and ACR testing. They also have systems in place to offer appointments for testing at the agreed frequency.

Healthcare professionals (GPs, nephrologists, cardiologists, diabetologists, rheumatologists, nurses and pharmacists) discuss and agree the frequency of eGFRcreatinine and ACR testing with adults who have, or at risk of, CKD and offer testing at the agreed frequency. They can then agree any appropriate treatment based on the results of testing.

Commissioners (clinical commissioning groups and NHS England) ensure that they commission services in which adults with, or at risk of, CKD have eGFRcreatinine and ACR testing at the frequency agreed with their healthcare professional. They might do this by checking that services have systems in place to identify adults with, or at risk of, CKD and offer appointments to discuss and agree the frequency of eGFRcreatinine and ACR testing.

Adults who have, or may be at risk of, CKD discuss and agree with their healthcare professional how often they should have tests to check how well their kidneys are working. They are offered blood and urine tests at the agreed frequency to find out if their CKD is worsening (progressing), or if they have kidney problems. The blood test is at least once a year for adults with CKD. People with CKD are offered information and education relevant to the cause of kidney disease, how advanced it is, any complications they may have and the chances of it getting worse, to help fully understand and make informed choices about treatment. They are also be able to get psychological support if needed – for example, support groups, counselling or support from a specialist nurse.

Source guidance

Chronic kidney disease in adults: assessment and management (2014) NICE guideline CG182, recommendations 1.1.27, 1.1.28 (key priority for implementation), 1.3.1 and 1.3.2 (key priority for implementation).

Definitions of terms used in this quality statement

Adults with CKD

CKD is defined as abnormalities of kidney function or structure present for more than 3 months, with implications for health. This includes:

  • people with markers of kidney damage, including albuminuria (ACR more than 3 mg/mmol), urine sediment abnormalities, electrolyte and other abnormalities due to tubular disorders, abnormalities detected by histology, structural abnormalities detected by imaging or a history of kidney transplantation

  • people with a glomerular filtration rate (GFR) of less than 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).

[NICE's guideline on chronic kidney disease in adults]

Adults at risk of CKD

Adults with any of the following risk factors:

  • diabetes

  • hypertension

  • acute kidney injury

  • 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 – for example, systemic lupus erythematosus

  • family history of end-stage kidney disease (GFR category G5) or hereditary kidney disease – for example, autosomal dominant polycystic kidney disease

  • opportunistic detection of haematuria

  • prescribed drugs that have an impact on kidney function, such as calcineurin inhibitors (for example, cyclosporin or tacrolimus), lithium and non-steroidal anti-inflammatory drugs (NSAIDs).

[NICE's guideline on chronic kidney disease in adults, recommendations 1.1.27 and 1.1.28 and expert opinion]

eGFRcreatinine testing

A blood test that estimates glomerular filtration rate (GFR) by measuring serum creatinine. It is used as an estimate of kidney function to identify kidney disease and monitor CKD progression. Clinical laboratories should use the Chronic Kidney Disease Epidemiology Collaboration (CKD‑EPI) creatinine equation to estimate GFRcreatinine, using creatinine assays with calibration traceable to standardised reference material.

[Adapted from NICE's guideline on chronic kidney disease in adults, recommendation 1.1.2]

Albumin:creatinine ratio (ACR) testing

A test used to detect and identify protein in the urine, which is a sign of kidney disease, and can be used to assess progression of CKD.

[Adapted from NICE's guideline on chronic kidney disease in adults, recommendation 1.1.18 and full guideline]

At the frequency agreed with their healthcare professional

The frequency of monitoring should be discussed and agreed by the person and their healthcare professional. Table 2 in NICE's guideline on chronic kidney disease in adults should be used to guide the frequency of GFR monitoring. Adults with CKD should be seen at least annually and adults at risk of CKD can be seen annually or less often for monitoring of eGFR. ACR does not need to be measured every time eGFR is measured, except when evaluating response to a treatment targeted at reducing proteinuria. Frequency of monitoring is determined by the stability of kidney function and the ACR level, and tailored to the individual according to:

  • the underlying cause of CKD

  • past patterns of eGFR and ACR (but be aware that CKD progression is often non-linear)

  • comorbidities, especially heart failure

  • changes to their treatment (such as renin–angiotensin–aldosterone system [RAAS] antagonists, NSAIDs and diuretics)

  • intercurrent illness

  • whether they have chosen conservative management of CKD.

[Adapted from NICE's guideline on chronic kidney disease in adults, recommendations 1.3.1 and 1.3.2 and full guideline]