NICE must end CKD confusion

Confusion over the diagnosis and management of chronic kidney disease (CKD) in primary care could be cleared up in a new NICE clinical guideline.

GPs currently refer to the Renal Association guidelines and CKD targets in the quality framework. But these do not consider the age effects on the estimated glomerular filtration rate (eGFR) formula and lack consensus on BP targets. They also fail to address cost-effectiveness issues over parathyroid hormone (PTH) tests for CKD stage three to five, according to an editorial in the British Journal of General Practice.

There are 27 points allocated to CKD in the quality framework.

Dr Ian Wilkinson, GPSI in renal medicine in Oldham, Lancashire, will sit on the development group for a NICE clinical guideline on CKD, due to be published in 2008.

ÔIt doesnÕt lessen the UK CKD guidelines, but I think weÕll start to learn lessons over time about their use in primary care,Õ he said. Evidence suggests that the eGFR formula leads to overdiagnosis of CKD in the elderly because renal function declines with age.

Research published last year showed that having an eGFR indicative of stage three CKD had little effect on mortality in patients over 65.

ÔThere is going to be a NICE CKD guideline in 2008 and I think we might start to get reference to age,Õ said Dr Wilkinson. Neither the Renal Association guideline nor the quality framework consider the effect of age on eGFR. Current BP targets for CKD are also confusing.

The Renal Association suggests a target of 130/80 mmHg and the quality framework 140/85 mmHg.

Kent GP Dr Rubin Minhas, CHD lead for Medway PCT, said: ÔWeÕve got too many different targets without any justification for why theyÕre different.Õ

South London GP Dr Penny Ackland, who helped draw up NICE clinical guidance on management of anaemia in CKD, said GPs should be aiming for the Renal Association target: ÔThereÕs a suggestion that to protect the nephrons of people with CKD, they need far smaller pressure going to the nephrons. Even in stroke and heart disease patients, one can probably get away with a higher BP.Õ

She also backed calls for the cost-effectiveness of PTH to be evaluated.

CKD guidance

  • eGFR formula fails to account for age-related decline of kidney function.
  • BP targets differ. Renal Association advises 130/80mmHg and the quality framework 140/85mmHg.
  • Patients with CKD stage three to five recommended to undergo PTH tests.

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