News from the Renal Association: new CKD Guidelines

by Charles Richard Vernon Tomson, DM, FRCP

 

Dr C.R.V. Tomson Department of Nephrology Southmead Hospital Bristol, United Kingdom

 

As in most other European countries, late referral to nephrologists of patients requiring Renal Replacement Therapy (RRT) is a significant problem in the UK. However, the number of available nephrologists in the UK is limited, and so unselective ‘early referral’ of all patients with Chronic Kidney Disease (CKD) is not practicable either. The Joint Specialty Committee on Renal Medicine of the Royal College of Physicians of London and the Renal Association therefore proposed the formation of a working party to develop guidelines for the UK on the identification, management, and referral of adults with CKD. The working party included representatives from the Royal College of General Practitioners, the Association of Clinical Biochemists, the British Geriatrics Society, Diabetes UK, and the National Kidney Federation, representing patients. Our over-riding aim was to ensure that patients with CKD get the right care in the right place at the right time. This involved a detailed analysis of when nephrologists add value, and when care can just as safely, and more efficiently, be given by general practitioners in the primary care setting. The guideline document has now been published, with an evidence base that includes 546 references to the primary literature and existing UK guidelines.

The guidelines recommend the use of measurement of serum creatinine and dipstick urinalysis for proteinuria as the primary tests for identification of patients with CKD, and give detailed guidance on which patients should undergo these tests. Testing for ‘microalbuminuria’ is only recommended in patients with diabetes mellitus. The use of the revised 4-variable MDRD formula for estimation of eGFR is endorsed; this has subsequently become the policy of the Department of Health for England, which has recommended that all clinical biochemistry laboratories report eGFR using this formula (after alignment of the creatinine results to the IDMS standard). The 5-stage K/DOQI classification of CKD has been adopted. For routine assessment of proteinuria, the use of random urine protein:creatinine ratios is recommended for non-diabetics, followed by a fasting sample to exclude postural proteinuria if the first sample proves positive.
For patients identified as having CKD, detailed recommendations are given on the frequency and tests required for follow-up in primary care – including, for instance, a minimum 6-monthly measurement of serum creatinine in stage 3 CKD.

Detailed guidelines are given for management of cardiovascular risk factors and for the detection and management of disordered bone metabolism. Detailed referral criteria are given, enabling primary care physicians to identify patients who would benefit from referral (for instance, nephrotic syndrome; refractory hypertension with features suggesting renal vascular disease; all stage 4 and 5 CKD). In addition to the full guidelines, a variety of educational materials have been developed, including a concise version, a web-based version, and a one-page leaflet; a modular educational courses for primary care nurses is also in preparation.
National audits of the rate of late referral of patients requiring RRT, as well as audits of the quality of care and monitoring of patients with stage 3 CKD, are planned, in the hope that these will reveal progressive improvement in the care of this group of patients.

The full guidelines are available from The Royal College of Physicians.

Price £17.00 (UK) £19.00 (overseas)
ISBN 1 86016 276
To order your copy call 00 44 20 7935 1174 ext 358 or visit

http://www.rcplondon.ac.uk/pubs/brochures/pub_print_CKD.htm