Commissioning guides
Published 01 July 2012

Early identification and management of chronic kidney disease in adults

This is an extract from the commissioning guide. The complete commissioning guide is available at www.nice.org.uk/guidance/cmg37

2 Specifying a service for the early identification and management of chronic kidney disease in adults

The key components of a service for the early identification and management of chronic kidney disease (CKD) in adults are:

  • early identification and ongoing investigations for people with CKD

  • management of CKD

  • developing a high-quality integrated service for the early identification and management of CKD.

2.1 Early identification and ongoing investigations for people with chronic kidney disease

The NICE quality standard on CKD states that:

People with risk factors for CKD are offered testing and people with CKD are correctly identified. (Quality statement 1)

NICE clinical guideline CG73 recommends that people with the following risk factors are offered testing for CKD:

  • diabetes

  • hypertension

  • cardiovascular disease (ischaemic heart disease, chronic heart failure, peripheral vascular disease and cerebral vascular disease)

  • structural renal tract disease, renal calculi or prostatic hypertrophy

  • multisystem diseases with potential kidney involvement – for example, systemic lupus erythematosus

  • family history of stage 5 CKD or hereditary kidney disease

  • opportunistic detection of haematuria or proteinuria.

NICE clinical guideline CG73 also recommends that glomerular filtration rate (GFR) is monitored in people prescribed drugs known to be nephrotoxic such as calcineurin inhibitors and lithium. The GFR needs to be checked at least annually in people receiving long-term systemic non-steroidal anti-inflammatory drug (NSAID) treatment.

Commissioners should note the recommendations 1.1.10 to 1.1.20 and see recommendation 1.1.11 below for the detection and identification of proteinuria and haematuria. They should also ensure that GPs are aware of the need to test people presenting with the risk factors above.

  • To detect and identify proteinuria, use urine ACR in preference, as it has greater sensitivity than PCR for low levels of proteinuria. For quantification and monitoring of proteinuria, PCR can be used as an alternative. ACR is the recommended method for people with diabetes.

Commissioners may also wish to refer to the commissioning and benchmarking tool and the NICE costing report on CKD to estimate the level of service needed locally, associated costs and any likely impact on laboratory contracts.

In order to achieve optimal use of resources and to support NHS Quality, Innovation, Productivity and Prevention (QIPP) commissioners should be aware of the interventions that the recommendations state should not be used (1.1.23, 1.1.10, 1.1.17).

  • Do not use reagent strips to identify proteinuria unless they are capable of specifically measuring albumin at low concentrations and expressing the result as an ACR.

  • When testing for the presence of haematuria, use reagent strips rather than urine microscopy.

    • Evaluate further if there is a result of 1+ or more.

    • Do not use urine microscopy to confirm a positive result.

  • In the absence of the above risk factors, do not use age, gender, or ethnicity as risk markers to test people for CKD. In the absence of metabolic syndrome, diabetes or hypertension, do not use obesity alone as a risk marker to test people for CKD.

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 GFR alone, whereas stages 1 and 2 also require the presence of persistent proteinuria, albuminuria or haematuria, or structural abnormalities.

NICE clinical guideline CG73 makes recommendations on the frequency and type of investigations for CKD including the measurement of kidney function using GFR. Commissioners are advised to refer to the recommendations 1.1.1 to 1.1.9 to ensure that services are investigating and detecting people with CKD in accordance with NICE guidance.

2.2 Management of chronic kidney disease

The NICE quality standard on CKD states that:

People with CKD are assessed for disease progression. (Quality statement 6)

Commissioners should specify that the management of chronic kidney disease includes assessment for the identification of progressive CKD[3]. Commissioners may wish to refer to the NICE clinical guideline 73 audit support criteria 3 and 8 to measure current practice against the recommendations on monitoring disease progression.

Commissioners should also ensure that the management of chronic kidney disease includes management of comorbidities and related complications, and that this is included within the service specification.

The NICE quality standard on CKD states that:

People with CKD are assessed for cardiovascular risk[4]. (Quality statement 4)

Commissioners need to ensure that local arrangements include assessment of people with CKD for cardiovascular risk. Healthy lifestyle factors including smoking, weight control and exercise should be discussed. Where dietary intervention is indicated, an appropriately trained health professional should discuss the risks and benefits of dietary protein restriction. This should occur within the context of education, detailed dietary assessment and supervision. It should also offer dietary advice concerning potassium, phosphate, protein, calorie and salt intake to people with progressive CKD.

Commissioners should note that cardiovascular risk is higher in some black and minority ethnic groups, and commissioners should therefore assess their local demographics when planning services.

The NICE quality standard on CKD states that:

People with CKD who may benefit from specialist care are referred for specialist assessment in accordance with NICE guidance. (NICE quality statement 2)

Commissioners also need to ensure that referral pathways are in place so that people with CKD who would benefit from specialist care can be referred in accordance with NICE clinical guideline CG73. Commissioners may wish to consider monitoring referrals and waiting times to ensure that access to specialist services is appropriate, effective and timely. NICE clinical guideline CG73 makes the following recommendations (1.6.2 to 1.6.5):

  • Consider discussing management issues with a specialist by letter, email or telephone in cases where it may not be necessary for the person with CKD to be seen by the specialist

  • Once a referral has been made and a plan jointly agreed, it may be possible for routine follow-up to take place at the patient's GP surgery rather than in a specialist clinic. If this is the case, criteria for future referral or re-referral should be specified.

  • Take into account the individual's wishes and comorbidities when considering referral.

  • People with CKD and renal outflow obstruction should normally be referred to urological services, unless urgent medical intervention is required – for example, for the treatment of hyperkalaemia, severe uraemia, acidosis or fluid overload.

NICE clinical guideline CG73 makes specific recommendations (1.8.1 to 1.8.22) in relation to pharmacotherapy and specifically for blood pressure control, choice of antihypertensive agents, treatment with angiotensin-converting enzyme (ACE) inhibitors/angiotensin-II receptor blockers (ARBs), statins and antiplatelet drugs and other complications including bone metabolism and osteoporosis and anaemia.

Commissioners should refer to NICE clinical guideline CG73 for further information, the NICE quality standard statement 5 for blood pressure control and NICE clinical guideline CG114 'Anaemia management in people with chronic kidney disease'. Commissioners can also view the NICE podcast on anaemia management in CKD.

2.3 Developing high-quality integrated services for the early identification and management of chronic kidney disease in adults

Commissioners should ensure that professionals develop and maintain current agreed care plans (verbal or written) for people with CKD appropriate to the stage and rate of progression of CKD. This applies to all areas of care across the care pathway and all stages of the disease. Care planning should include an advance care plan for end-of-life care if appropriate, as well as care planning for people who have an early diagnosis of CKD where care planning principles may be applied. Commissioners may wish to reflect this in the service specifications and monitor it through contract monitoring arrangements, while also ensuring that local arrangements include the promotion of access to Renal Patient View. A guide to implementing kidney care plans is available from NHS Kidney Care.

Commissioners should also ensure that people with CKD are offered education and information that are tailored to the stage and cause of CKD, the associated complications and the risk of progression. When developing information or education programmes, NICE recommends that people with CKD should be involved in their development from the outset.

Commissioners are advised to review arrangements to ensure that people with established renal failure have access to psychosocial support (which may include support with personal, family, financial, employment and/or social needs) appropriate to their circumstances. Commissioners may wish to refer to the cost impact and commissioning assessment for the quality standard for chronic kidney disease for more information.

When commissioning services for chronic kidney disease, commissioners should consider the whole pathway and should work in collaboration with specialised commissioning groups and local Kidney Care Networks. Services should be able to deliver regular and frequent application of home or self-care dialysis for those people on long term dialysis. Commissioners will need to consider any cost implications where current practice differs from the NICE recommendations.

Commissioners may wish to consider the cost implications where current patient transport provision is lacking. Furthermore, they should take the opportunity to identify potential cost savings where inefficiencies exist, as demonstrated in a QIPP case study for a transport service for dialysis patients: to improve quality.

Commissioners should also ensure that people who become acutely unwell have immediate access to services, and that staff are competent to review patient medication, and assess volume status and renal function. Commissioners may wish to work with clinicians and carry out clinical audit to determine the root cause of acute kidney injury across primary and secondary care and assess the need for additional critical care and renal beds to ensure that step-up care is available when necessary. See also the Renal Association clinical practice guideline: acute kidney injury and Academy of Medical Royal Colleges Acute kidney injury: a competency framework.

2.4 Service models

Integrated services for the early identification and management of CKD in adults can be commissioned in a number of different ways, and mixed models of provision may be appropriate across a local health economy including shared care models across primary and secondary care (for people with stage 3 CKD) or integrated chronic disease management arrangements (for people with stage 4 and some stage 5).

This commissioning guide covers early identification and management of chronic kidney disease in adults within the pathway for chronic kidney disease. To maximise the use of resources and improve health outcomes for people with CKD, commissioners should commission the whole condition-specific pathway for CKD. They should integrate this with a generic model of care for people with long-term conditions. The long-term conditions workstream of the Quality, Innovation, Productivity and Prevention (QIPP) programme supports local areas in implementing a generic model of care for people with long-term conditions. The key outcome for patients with long-term conditions is to provide continuous care-coordination within the community and across organisations. This allows care-coordination to remain with one health or social care professional throughout the pathway, and not get transferred as a patient moves from one service to another.

Commissioners should commission services that:

  • Reflect the needs of their population and manage those at risk to prevent disease progression.

  • Empower patients to maximise self-management, including ensuring patients have a care plan and appropriate information and knowledge about how to manage their condition.

  • Provide joined up and personal services, particularly in community and primary care, that work together closely and effectively.

General examples include:

(Please note – these examples are offered to share good practice and NICE makes no judgement on the compliance of this service with its guidance).

2.5 Service specification

Commissioners should collaborate with clinicians, local stakeholders, and service users, when determining what is needed from services for the early identification and management of chronic kidney disease in order to meet local needs. The services should be patient-centred and integrated with other elements of care for patients with chronic kidney disease, and where appropriate, other long-term conditions.

NICE quality standards provide commissioners with definitions of high-quality care across a care pathway. Commissioners can use the quality standards to improve services by including quality statements and measures within the service specification element of the standard contract, and by measuring performance against them. If poor performance is identified, commissioners can discuss the level of performance with their providers and address any issues or concerns before introducing more formal contractual remedies.

Commissioners may use quality standards to ensure that high-quality care is being commissioned through the contracting process, by establishing key performance indicators as part of the tendering process. They may also use quality standards to incentivise provider performance by using the indicators in association with incentive payments such as Commissioning for Quality and Innovation (CQUIN).

From 2012/13, the NHS Commissioning Board will draw on NICE quality standards to adapt the national outcomes into outcomes and indicators that are meaningful at a local level. These will be used to hold GP commissioning consortia to account for their contribution to improving outcomes, and will be set out in the NHS outcomes framework 2012–13.

The service specification needs to consider:

  • the quality statements as set out in the NICE Quality standard for chronic kidney disease

  • the required competencies of, and training for, staff responsible for providing the service, see The Renal Association – education and training and British Renal Society – Workforce planning

  • the expected number of patients (this should take into account how quickly any changes in service provision are likely to take place)

  • ease of access and service location; commissioners should engage with service users and other relevant individuals and organisations locally

  • care and referral pathways including referral criteria and requirements related to shared care plans and links with existing healthy lifestyle services. Arrangements for the discussion of management issues with specialists by letter, email or telephone should be considered as well as the routine follow-up of patients taking place at the patient's GP surgery rather than in a specialist clinic. Criteria for future referral or re-referral should be specified

  • integration with other services for long term conditions and existing healthy lifestyle services with consideration of the NHS Health Check

  • measuring outcomes

  • information and audit requirements, including IT support and infrastructure

  • planned service development, setting out any productivity improvements including redesign, quality and equitable access

  • address any safeguarding concerns and promote the welfare of children and vulnerable adults

  • service monitoring criteria (see section 5).

Useful sources of information may include:



[3] NICE CG73 defines progressive CKD as a decline in eGFR of more than 5 ml/min/1.73 m2 within 1 year, or more than 10 ml/min/1.73 m2 within 5 years.

[4] Renal Association clinical practice guideline: Cardiovascular disease in CKD, recommendations 1.1 and 1.2.