Quality statement 2: Blood pressure control

Quality statement

Adults with chronic kidney disease (CKD) have their blood pressure maintained within the recommended range. [2011, updated 2017]

Rationale

People with CKD are at a higher risk of high blood pressure. Maintaining blood pressure within a target range reduces the risk of cardiovascular disease, CKD progression and mortality.

Quality measures

Structure

a) Evidence of local systems to identify and invite adults with CKD to have a blood pressure reading.

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

b) Evidence of the availability of equipment to take a blood pressure reading from adults with CKD.

Data source: Local data collection, for example, service specifications.

Process

a) Proportion of adults with CKD without diabetes and with an ACR below 70 mg/mmol whose systolic blood pressure is between 120–139 mmHg and their diastolic blood pressure below 90 mmHg.

Numerator – the number in the denominator whose systolic blood pressure is between 120–139 mmHg and their diastolic blood pressure below 90 mmHg.

Denominator – the number of adults with CKD without diabetes and with an ACR below 70 mg/mmol.

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 blood pressures below the recommended targets.

b) Proportion of adults with CKD and diabetes whose systolic blood pressure is between 120–129 mmHg and their diastolic blood pressure below 80 mmHg.

Numerator – the number in the denominator whose systolic blood pressure is between 120–129 mmHg and their diastolic blood pressure below 80 mmHg.

Denominator – the number of adults with CKD and diabetes.

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 blood pressures below the recommended targets.

c) Proportion of adults with CKD and an ACR of 70 mg/mmol or more whose systolic blood pressure is between 120–129 mmHg and their diastolic blood pressure below 80 mmHg.

Numerator – the number in the denominator whose systolic blood pressure is between 120–129 mmHg and their diastolic blood pressure below 80 mmHg.

Denominator – the number of adults with CKD and an ACR of 70 mg/mmol or more.

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 blood pressures below the recommended targets.

Outcomes

a) Prevalence of cardiovascular disease among people with CKD.

Data source: Local data collection, for example, audit of health records. The UK Renal Registry collects data on comorbidities of renal patients, including angina, heart failure and atrial fibrillation.

b) Incidence of cardiovascular events for people with CKD.

Data source: Local data collection, for example, audit of health records. The UK Renal Registry collects data on comorbidities of renal patients, including dates of heart failure, transient ischaemic attack, stroke and ST segment elevation myocardial infarction (STEMI).

c) Cardiovascular mortality rates among people with CKD.

Data source: Local data collection, for example, audit of health records. The UK Renal Registry collects data on the cause of death of renal patients.

d) Incidence of end-stage kidney disease.

Data source: Local data collection, for example, audit of health records. The UK Renal Registry collects data on the first date of renal replacement therapy or start of CKD stage 5 in renal patients.

What the quality statement means for different audiences

Service providers (general practices and secondary care services) ensure that systems are in place for adults with CKD to have their blood pressure maintained within the recommended range. This might involve having the equipment to take a blood pressure reading, using clinical IT systems to compare patients to the recommended range when entering a blood pressure reading, or flagging when patients need a blood pressure reading.

Healthcare professionals (GPs, nephrologists, nurses and pharmacists) monitor the blood pressure of adults with CKD and are aware of the recommended ranges. They support people to keep their blood pressure within the recommended range, for example, by starting or adjusting treatment, or advising on lifestyle changes.

Commissioners (clinical commissioning groups and NHS England) ensure that they commission services in which adults with CKD have their blood pressure maintained within the recommended range. They work with service providers to ensure that adults with CKD are identified, and have a blood pressure reading and any necessary support to maintain it within the recommended range.

Adults with CKD are supported to keep their blood pressure at a healthy level. If it is too high, their healthcare professional might offer medicine, or change the medicine they are taking, or suggest lifestyle changes, to help to control it.

Source guidance

Chronic kidney disease in adults: assessment and management (2014) NICE guideline CG182, recommendations 1.6.1 and 1.6.2.

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]

Recommended range

Blood pressure should be monitored and maintained within the following ranges:

  • In people with CKD aim to keep the systolic blood pressure below 140 mmHg (target range 120–139 mmHg) and the diastolic blood pressure below 90 mmHg.

  • In people with CKD and diabetes, and also in people with an ACR of 70 mg/mmol or more, aim to keep the systolic blood pressure below 130 mmHg (target range 120–129 mmHg) and the diastolic blood pressure below 80 mmHg.

[Adapted from NICE's guideline on chronic kidney disease in adults, recommendations 1.6.1 and 1.6.2]