This is an updated guideline from NICE on the investigation and management of CKD. The last major update was in 2014. This was published in Aug 21.
There are a few changes in this guideline. I will summarise these, then do a more detailed outline of management.
What has changed in this 2021 NICE update?
- eGFRcystatinC. This was added into the last update in an attempt to try to more accurately diagnose CKD. However its use is now not advised as there wasn’t enough evidence of its accuracy.
- Children and young adults have been bought into this guideline.
- Anaemia in CKD. The management of anaemia in CKD has been bought into this guideline too. It was in a separate guideline before this.
- Patients should have their renal function monitored for 3 yrs after an episode of AKI. This should be extended if they have AKI stage 3. They don’t advise on how long we should monitor AKI stage 3 patients for.
- Patients with gout should be monitored for CKD. This is a new addition to the guideline.
- Five-year risk of needing renal replacement. We should now be offering patients an idea of their 5 yr risk of needing renal replacement. See the details below for more information on how to do this. If the patient’s 5 yr risk of needing renal replacement is 5% or more, then we should refer onto secondary care.
- SGLT-2 inhibitors. We should offer adults with CKD and T2DM an SGLT-2 inhibitor, in addition to maximum ACEi / A2RB therapy, if their ACR is over 30 and if they ‘meet the criteria in the marketing authorisation’. Please don’t jump into actually doing this yet. Read the detailed section below on this for more information.
- Ethnicity and eGFR. In the previous guidelines there were different approaches in looking at eGFR in certain ethnic groups. This has now been dropped as it was felt that there wasn’t enough evidence to make these distinctions. There is an interesting BMJ article discussing this in more detail.
- Statins. A statin should be started in patients with CKD with a GFR < 60 and / or with albuminuria. Do not use a CVD risk scoring tool in these patients as it will underestimate their risk. This isn’t a new recommendation, but one that I have to admit to not always remembering, so felt it important to add in here.
- Proteinuria. An excellent visual guide on managing proteinuria has been released.
- Identifying CKD. There is another useful visual guide on identifying patients with CKD.
How should we be measuring renal function?
Measure eGFR and creatinine. Assess the patient for haematuria and proteinuria.
