NICE clinical guidelines
Issued: September 2008

Chronic kidney disease: Early identification and management of chronic kidney disease in adults in primary and secondary care

This is an extract from the guidance. The complete guidance is available at


Chronic kidney disease (CKD) describes abnormal kidney function and/or structure. It is common, frequently unrecognised and often exists together with other conditions (for example, cardiovascular disease and diabetes). When advanced, it also carries a higher risk of mortality. The risk of developing CKD increases with increasing age, and some conditions that coexist with CKD become more severe as kidney dysfunction advances. CKD can progress to established renal failure in a small but significant percentage of people.

CKD is usually asymptomatic. But it is detectable, and tests for detecting CKD are both simple and freely available. There is evidence that treatment can prevent or delay the progression of CKD, reduce or prevent the development of complications and reduce the risk of cardiovascular disease. However, because of a lack of specific symptoms people with CKD are often not diagnosed, or diagnosed late when CKD is at an advanced stage.

The 'National service framework for renal services' adopted the US 'National Kidney Foundation kidney disease outcomes quality initiative' (NKF-KDOQI) classification of CKD. This classification divides CKD into five stages. Stages 3–5 may be defined by glomerular filtration rate (GFR) alone, whereas stages 1 and 2 also require the presence of persistent proteinuria, albuminuria or haematuria, or structural abnormalities.

On average 30% of people with advanced kidney disease are referred late to nephrology services from both primary and secondary care, causing increased mortality and morbidity. Over 2% of the total NHS budget is spent on renal replacement therapy (dialysis and transplantation) for those with established renal failure.

Strategies aimed at earlier identification and (where possible) prevention of progression to established renal failure are therefore clearly needed. This clinical guideline seeks to address these issues by providing guidance on identifying:

  • people who have or are at risk of developing CKD

  • those who need intervention to minimise cardiovascular risk and what that intervention should be

  • those who will develop progressive kidney disease and/or complications of kidney disease and how they can be managed

  • those who need referral for specialist kidney care.