My name is Fernando Florido and I am a GP in the United Kingdom. In this video I go through the NICE guidelines “Chronic kidney disease: assessment and management” or NG203, Published on 25 August 2021
There is a Youtube version of this and other videos that you can access here:
· @nicegp : https://www.youtube.com/channel/UClrwFDI15W5uH3uRGuzoovw
The full NICE guideline on CKD can be found here:
· Website: https://www.nice.org.uk/guidance/ng203or as
· Or download here: https://1drv.ms/b/s!AiVFJ_Uoigq0lgvjCLLzwi5sLeq7?e=JC2Z0g
The Visual summaries on CKD can be found here:
· Or download here:
o Identifying CKD: https://1drv.ms/b/s!AiVFJ_Uoigq0lgxMqWAve0P2Uqmw?e=r9Gaj2
o Managing proteinuria:
https://1drv.ms/b/s!AiVFJ_Uoigq0lg2n86ZBA-LtN8Sx?e=3iUfe7
o Phosphate binders:
https://1drv.ms/b/s!AiVFJ_Uoigq0lg62GGYNQmkebxqF?e=nG7cm6
CKD tables- 1&2
· Download:https://1drv.ms/u/s!AiVFJ_Uoigq0lhN1Hnk7TV08C5lC?e=FaLGZo
Abbreviations: ACR, albumin creatinine ratio; CKD, chronic kidney disease; GFR, glomerular filtration rate.
Note: ACR monitoring should be individualised based on a person's individual characteristics, risk of progression and whether a change in ACR is likely to lead to a change in management.
The episodes on the NICE guideline on hypertension are here:
· Full guideline: https://youtu.be/dELO3enIhsI
· Flowchart: https://youtu.be/Ffa6IYrZWeo
· Shorts:
o https://youtu.be/qmLJtwu677I
o https://youtu.be/Izo_eSuECEU
o https://youtu.be/BnbcUPriJ9g
For guidance on SGLT2 inhibitors for adults with CKD and type 2 diabetes, see chronic kidney disease in NICE's guideline on type 2 diabetes in adults.
· Summary of guidance: CKD section of diabetes guideline 1.8.17
For adults with type 2 diabetes and CKD who are taking an ARB or an ACE inhibitor (titrated to the highest licensed dose that they can tolerate), offer an SGLT2 inhibitor (in addition to the ARB or ACE inhibitor) if:
· ACR is over 30 mg/mmol and
· they meet the criteria in the marketing authorisation (including relevant estimated glomerular filtration rate [eGFR] thresholds).
· Website: Diabetes guideline:
https://www.nice.org.uk/guidance/ng28/chapter/Recommendations#chronic-kidney-disease
For guidance on dapagliflozin for adults with CKD, with or without type 2 diabetes, see NICE's technology appraisal guidance on dapagliflozin for treating chronic kidney disease.
· Website:
https://www.nice.org.uk/guidance/ta775
· PDF:
· Or download here:
https://1drv.ms/b/s!AiVFJ_Uoigq0lg_O0S-awCfFqpI_?e=rrscuF
For recommendations on hyperkalaemia treatment in adults with categories G3b to G5 chronic kidney disease, see NICE's technology appraisals on sodium zirconium cyclosilicate and patiromer.
· Website:
o Zirconium: https://www.nice.org.uk/guidance/ta599
o Patiromer: https://www.nice.org.uk/guidance/ta623
· PDF:
o Zirconium:
o Patiromer: https://www.nice.org.uk/guidance/ta623/resources/patiromer-for-treating-hyperkalaemia-pdf-82609015577029
· Or download here:
o Zirconium:
https://1drv.ms/b/s!AiVFJ_Uoigq0lhLUkpx5T4E0mrE_?e=XcfIQt
o Patiromer: https://1drv.ms/b/s!AiVFJ_Uoigq0lhARwG8vfMNKvISz?e=VEsKLm
Follow the recommendations in NICE's guideline on cardiovascular disease: risk assessment and reduction, including lipid modification for the use of statins in adults with CKD.
· Website: https://www.nice.org.uk/guidance/cg181
· PDF:
· Or download here:
https://1drv.ms/b/s!AiVFJ_Uoigq0lhEqiQX4EhaMN2A3?e=7u5KIK
Follow the MHRA safety advice on recombinant human erythropoietins:
· Website:
https://www.gov.uk/drug-safety-update/recombinant-human-erythropoietins-new-advice-for-prescribing
· Summary of advice:
Recombinant human erythropoietins: new advice for prescribing
Over-correction of haemoglobin concentration may increase the risk of death and serious cardiovascular events in patients with chronic kidney disease; it may increase the risk of thrombosis and related complications in patients with cancer.
4-variable Kidney Failure Risk Equation
A person's 5-year risk of needing renal replacement therapy (defined as the need for dialysis or transplant) is estimated, as in Major 2019, as:
In the above, eGFR is reported in ml/min/1.73 m2 and ACR in mg/mmol. Where the term 'male' is used, this should be replaced by a 1 if the person being assessed is male, and a 0 if they are female. This equation and its coefficients are validated in a UK population, and it is important to use this version, and not a version validated in another country.
Hello everyone and welcome to the channel.
Today we are going to look at the NICE guidelines on CKD.
My name is Fernando Florido and I am a GP in the United Kingdom. So, let’s get started.
The first thing that I want to say is that obviously this video is a summary of the guideline. I have removed anything that I thought was common-sense advice (e.g. involve patients in the decision making process, offer information, etc) but on this occasion I have removed all aspects about children and young people with CKD. Although their management is very similar to adults in many ways, most patients with CKD that we will see in general practice will be adults and this is why I have focused on them
In terms of measuring kidney function, we will look at the eGFR. We need to remember that “e” in eGFR means “estimated” and that eGFRcreatinine may be less reliable in certain situations, for example, acute kidney injury, pregnancy, oedematous states, and has not been well validated in certain ethnic groups, for example, black, and Asian ethnic groups. Also, reduced muscle mass will lead to overestimation and increased muscle mass to underestimation of the GFR and therefore we will need to interpret eGFRcreatinine with caution in extremes of muscle mass, e.g., in bodybuilders, amputation or muscle wasting disorders.
And we shouuldn’t forget to advise patients not to eat any meat in the 12 hours before having a blood test for eGFRcreatinine. This is because meat contains creatinine so when you eat meat the serum creatinine naturally increases. Serum creatinine used in eGFR calculations. And so, eating less (or no meat) will cause the creatinine to fall and consequently, the eGFR to improve.
The eGFR value is given as a whole number if it is 90 or less, or as 'greater than” 90
If eGFR is greater than 90, we will use an increase in serum creatinine of more than 20% to infer significant reduction in kidney function.
We need to interpret eGFR values of 60 or more with caution, as estimates of GFR become less accurate as the true GFR increases.
And we will also confirm a first ever eGFR result of less than 60 by repeating it within 2 weeks.
When it comes to proteinuria, we will not use reagent strips to detect it. We will:
· use urine ACR rather than protein:creatinine ratio (PCR) because of the greater sensitivity for low levels of proteinuria. However, when ACR is 70 mg/mmol or more, PCR can be used as an alternative to ACR.
And we will routinely measure ACR in:
If unexplained proteinuria is found on a reagent strip, we need to offer testing for CKD using eGFRcreatinine and ACR.
When it comes to haematuria, we will use reagent strips to test for it and:
We will regard 2 out of 3 positive reagent strip tests as confirmation of persistent invisible haematuria. Otherwise, it may be transient haematuria
Persistent invisible haematuria, with or without proteinuria, should prompt investigation for urinary tract malignancy in appropriate age groups
Persistent invisible haematuria in the absence of 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.
There are certain patients who should be regularly tested for CKD.
We will monitor GFR at least annually if medicines that can adversely affect kidney function, such as calcineurin inhibitors (for example, ciclosporin or tacrolimus), lithium or non-steroidal anti-inflammatory drugs (long-term chronic use of NSAIDs) are given.
We will also do eGFRcreatinine and ACR to people with any of the following risk factors:
We will also monitor people for the development or progression of CKD for at least 3 years after acute kidney injury (longer for people with acute kidney injury stage 3) even if eGFR has returned to baseline.
There is a classification of CKD depending on the ACR level (A1, A2 and A3) and the GFR level (G1 to G5).
§ A1: ACR less than 3 mg/mmol
§ A2: ACR 3 to 30 mg/mmol
§ A3: ACR over 30 mg/mmol
§ G1: GFR 90 or over
§ G2: GFR 60 to 89
§ G3a: GFR 45 to 59
§ G3b: GFR 30 to 44
§ G4: GFR 15 to 29
§ G5: GFR under 15
We need to be aware that:
The classification table (table 1) with the risk assessment of every category can be found in the video description.
We will offer a renal ultrasound scan to all adults with CKD who:
When it comes to the frequency of monitoring, we will bear in mind that CKD is not progressive in many people.
There is also a table (table 2) to guide the minimum frequency of eGFRcreatinine monitoring depending of the CKD classification- you can see this table in the video description too.
Generally, it would be:
1. once a year for G1, G2 and G3a if the ACR is less than 30
2. twice a year for G3a A3 (that is ACR more than 30) and also G3b and G4 if the ACR is less than 30
3. three times a year for G4A3 (that is ACR more than 30)
4. four times a year or more for G5
Monitoring should be tailored according to:
We will define accelerated progression of CKD as:
If we are worried and we want to identify the rate of progression of CKD:
Risk factors for CKD progression are:
When it comes to patient education, we will encourage exercise, a healthy weight and stop smoking. We will also offer dietary advice about potassium, phosphate, calorie, and salt intake appropriate to the severity of CKD. But we will not offer low-protein diets.
There is a 4-variable Kidney Failure Risk Equation that can be used to give information about the 5-year risk of needing. Those who are interested in it can find more details in the video description.
We will refer for specialist assessment if they have:
We will refer people with CKD and renal outflow obstruction to urological services
When it comes to blood pressure control in adults with CKD and an ACR under 70, we will aim for a clinic BP below 140/90 mmHg
However, in CKD and an ACR of 70 or more, aim for a clinic BP below 130/80.
In order to treat hypertension, if the ACR is 30 or less (that is ACR categories A1 and A2), we will simply follow the NICE guideline on hypertension. And you can check out the corresponding episode on this channel.
But for people with CKD who have hypertension and an ACR over 30 (that is an ACR category A3), we will definitely offer an ARB or an ACE inhibitor and we will titrate it to the highest licensed dose that the person can tolerate. If they also have diabetes, we will also give an ARB or ACEI if the ACR is 3 mg/mmol or more.
SGLT2 inhibitors have been proven to help CKD in both people with and without diabetes. The guidance on their use is outside the scope of this guideline but I will put links to the guidance in the video description.
Going back to the renin–angiotensin system antagonists, that is, ARBs and ACEIs, we will not offer a combination of both these agents.
We will measure potassium and eGFR before starting an ARB or ACEI and between 1 and 2 weeks after starting treatment and after each dose increase. More frequent monitoring of serum potassium may be needed if medicines known to promote hyperkalaemia are prescribed alongside them
We will not routinely offer an ARB or ACEI if their pre-treatment potassium is greater than 5.0 mmol/litre. In these cases, we will:
We will stop ARBs and ACEIs if the potassium level increases to 6.0 mmol/litre or more and other medicines known to promote hyperkalaemia have been discontinued.
There is a separate guidance on hyperkalaemia treatment- see link in the video description.
Because their mode of action, ARBs and ACEIs can reduce the GFR and increase the creatinine levels. However, after starting or increasing the dose of an ACEI or ARB, we will not modify the dose if either:
If the eGFR decrease is 25% or more, or the increase in creatinine is 30% or more:
The advice on statins inn CKD is covered in a different NICE guideline. I will put it link to it in the video description.
We will offer antiplatelet medicines only for the secondary prevention of cardiovascular disease, but we need to be aware of the increased risk of bleeding.
When it comes to anaemia, we will consider investigating and managing anaemia in CKD if:
And in people with anaemia:
We will need to determine the iron status in these cases and we will test for iron deficiency every 3 months, or every 1 to 3 months if haemodialysis. And to diagnose iron deficiency, we will:
Equally we will not routinely measure erythropoietin levels for the diagnosis or management of anaemia of CKD.
In order to manage anaemia, there is separate guidance and I will put the link to it in the video description. But the management of anaemia in CKD is based on iron therapy, ESAs (erythropoietic stimulating agents) and blood transfusions.
We will not start ESA therapy without managing possible iron deficiency.
In people treated with iron, serum ferritin levels should not rise above 800 micrograms/litre. In order to prevent this, we will review the dose of iron when serum ferritin levels reach 500 micrograms/litre.
We will not prescribe androgens, supplements of vitamin C, folic acid or carnitine as adjuvants specifically for the treatment of anaemia of CKD. But we will treat clinically relevant hyperparathyroidism to improve the management of the anaemia.
We will avoid blood transfusions in people in whom kidney transplant is an option. This is because exposure to multiple blood donations may cause alloimmunisation to human leucocyte antigen or HLA class I antigens on white blood cells. HLA antibodies can react with the transplanted kidney leading to higher rates of acute rejection and poorer long-term graft survival. However, the risk of alloimmunisation has reduced since the introduction of universal leucodepletion of blood components.
The dose and frequency of ESA should be:
And we will not routinely correct Hb to normal levels with ESAs in people with anaemia of CKD.
There is MHRA advice on the prescribing of ESAs. I will put in the video description the link to these details. In particular, we will follow their advice to avoid Hb levels above 120 g/litre because of the increased risk of death and serious adverse cardiovascular events in people with CKD. We will use the lowest dose of ESA to provide adequate control of the anaemia symptoms and we will consider accepting Hb levels below the aspirational range if:
The use of ACEIs or ARBs is not precluded, but if they are used, we need to be aware that an increase in ESA therapy may be needed.
We will offer iron to people with anaemia of CKD who are receiving ESAs to achieve:
Most adults will need 500 to 1,000 mg of iron (equivalent doses for children) in a single or divided dose depending on the preparation. Intravenous iron should be administered in a setting with facilities for resuscitation.
We will also offer intravenous iron therapy to adults with anaemia of CKD who are iron deficient and who are receiving ESA therapy. In these cases we will only offer oral iron if:
When offering intravenous iron therapy to people not having haemodialysis, consider high‑dose low‑frequency intravenous iron as the treatment of choice.
High-dose and low-frequency iron is a maximum of 2 infusions, with a minimum of 500 mg of iron in each infusion for adults. Low dose and high frequency is more than 2 infusions with 100 mg to 200 mg of iron in each infusion for adults.
We will not check iron levels earlier than 1 week after intravenous iron and we will carry out routine ferritin every 1 to 3 months to prevent iron overload
In anaemia of CKD, we will monitor Hb:
After other causes of anaemia have been excluded, we will regard anaemia of CKD as resistant to ESAs when:
In people with CKD, pure red cell aplasia (PRCA) is indicated by a low reticulocyte count, together with anaemia and the presence of neutralising antibodies. In addition, aluminium toxicity should be considered as a potential cause of ESA resistance after other causes have been excluded.
If aluminium toxicity is suspected in a person with anaemia of CKD having haemodialysis, we will need to test for desferrioxamine and review the management
We will consider specialist referral for people with ESA‑induced pure red cell aplasia or PRCA.
We will take into account symptoms, quality of life, underlying conditions and the chance of a future successful kidney transplant, in addition to Hb levels, when thinking about the need for red cell transfusion.
Hyperphosphataemia in people with CKD stage 4 or 5 can be common and when it comes to managing hyperphosphataemia, a specialist renal dietitian should be involved.
And before starting phosphate binders we will optimise:
We will first offer adults with CKD stage 4 or 5 and hyperphosphataemia calcium acetate to control serum phosphate levels.
We will then offer sevelamer carbonate if calcium acetate is not indicated (for example, because of hypercalcaemia or low serum parathyroid hormone levels) or not tolerated.
If calcium acetate and sevelamer carbonate cannot be used, we will consider:
We will only consider lanthanum carbonate if other phosphate binders cannot be used.
If patients remain hyperphosphataemic after taking the maximum dose of a calcium-based phosphate binder:
At every routine clinical review, we will assess the person's phosphate, taking into account:
There are other complications in CKD such as the effect on bone metabolism and osteoporosis.
We will not routinely measure calcium, phosphate, parathyroid hormone and vitamin D levels in adults with a GFR of 30 ml/min/1.73 m2 or more (GFR category G1, G2 or G3). But we will measure serum calcium, phosphate and parathyroid hormone concentrations in adults with a GFR of less than 30 ml/min/1.73 m2 (GFR category G4 or G5).
We will offer bisphosphonates if indicated for the prevention and treatment of osteoporosis in adults with a GFR of 30 ml/min/1.73 m2 or more (GFR category G1, G2 or G3).
We will not routinely offer vitamin D supplementation to manage or prevent CKD–mineral and bone disorders but we will offer colecalciferol or ergocalciferol to treat proven vitamin D deficiency.
If vitamin D deficiency has been corrected and symptoms of CKD–mineral and bone disorders persist, we will offer alfacalcidol or calcitriol to people with a GFR of less than 30 ml/min/1.73 m2 (GFR category G4 or G5) and we will monitor the calcium and phosphate levels.
Finally, we will consider oral sodium bicarbonate supplementation for if both:
We have come to the end of this video. I hope that you have found it useful and, if so, please hit the like and subscribe buttons. Thank you for watching and good-bye
