Chronic kidney disease: assessment and management

Do not use reagent strips to identify proteinuria in children and young people. [2021]

Do not use reagent strips to identify proteinuria in adults unless they are capable of specifically measuring albumin at low concentrations and expressing the result as an albumin:creatinine ratio (ACR). [2008]

For the initial detection of proteinuria in adults, children and young people:

• use urine ACR rather than protein:creatinine ratio (PCR) because of the greater sensitivity for low levels of proteinuria

• check an ACR between 3 mg/mmol and 70 mg/mmol in a subsequent early morning sample to confirm the result.
  
  A repeat sample is not needed if the initial ACR is 70 mg/mmol or more. [2021]

Regard a confirmed ACR of 3 mg/mmol or more as clinically important proteinuria. [2021]

Measure proteinuria with urine ACR in the following groups:

• adults, children and young people with diabetes (type 1 or type 2)

• adults with an eGFR of less than 60 ml/min/1.73 m²

• adults with an eGFR of 60 ml/min/1.73 m² or more if there is a strong suspicion of CKD

• children and young people without diabetes and with creatinine above the upper limit of the age-appropriate reference range.
  
  When ACR is 70 mg/mmol or more, PCR can be used as an alternative to ACR. [2021]

Use reagent strips to test for haematuria in adults, children and young people (see recommendation 1.1.14 for people who should be tested for haematuria):

• Evaluate further for results of 1+ or higher.

• Do not use urine microscopy to confirm a positive result. [2021]

When there is the need to differentiate persistent invisible haematuria in the absence of proteinuria from transient haematuria, regard 2 out of 3 positive reagent strip tests as confirmation of persistent invisible haematuria. [2008]

Persistent invisible haematuria, with or without proteinuria, should prompt investigation for urinary tract malignancy in appropriate age groups (see NICE's guideline on suspected cancer: recognition and referral). [2008]

Persistent invisible haematuria in the absence of proteinuria should be followed up annually with repeat testing for haematuria (see recommendations 1.1.17 and 1.1.18), proteinuria or albuminuria, GFR and blood pressure monitoring as long as the haematuria persists. [2008]

Monitor GFR at least annually in adults, children and young people who are taking medicines that can adversely affect kidney function, such as calcineurin inhibitors (for example, ciclosporin or tacrolimus), lithium or non-steroidal anti-inflammatory drugs (long-term chronic use of NSAIDs). [2021]

Offer testing for CKD using eGFRcreatinine and ACR to adults with any of the following risk factors:

• diabetes

• hypertension

• previous episode of acute kidney injury

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

• structural renal tract disease, recurrent renal calculi or prostatic hypertrophy

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

• gout

• family history of end-stage renal disease (GFR category G5) or hereditary kidney disease

• incidental detection of haematuria or proteinuria. [2021]

Offer testing for CKD using eGFRcreatinine and ACR to children and young people with any of the following risk factors:

• previous episode of acute kidney injury

• solitary functioning kidney. [2021]

Consider testing for CKD using eGFRcreatinine and ACR in children and young people with any of the following risk factors:

• low birth weight (2,500 g or lower)

• diabetes

• hypertension

• cardiac disease

• structural renal tract disease or recurrent renal calculi

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

• family history of end-stage renal disease (GFR category G5) or hereditary kidney disease

• incidental detection of haematuria or proteinuria. [2021]

Do not use any of the following as risk factors indicating testing for CKD in adults, children and young people:

• age

• gender

• ethnicity

• obesity in the absence of metabolic syndrome, diabetes or hypertension. [2021]

Monitor adults, children and young people for the development or progression of CKD for at least 3 years after acute kidney injury (longer for people with acute kidney injury stage 3) even if eGFR has returned to baseline. [2021]

For guidance on ACR monitoring for children and young people with diabetes, see the NICE guideline on diabetes in children:

• monitoring for complications and associated conditions of type 1 diabetes

• monitoring for complications and associated conditions of type 2 diabetes. [2021]

Agree a plan to establish the cause of CKD during an informed discussion with the person with CKD, particularly if the cause may be treatable (for example, urinary tract obstruction, medicines that can adversely affect kidney function or glomerular disease). [2014]

Use the person's GFR and ACR categories (see table 1) to indicate their risk of adverse outcomes (for example, CKD progression, acute kidney injury, all-cause mortality and cardiovascular events) and discuss this with them. [2014]

Offer a renal ultrasound scan to all adults with CKD who:

• have accelerated progression of CKD (see recommendation 1.3.5)

• have visible or persistent invisible haematuria

• have symptoms of urinary tract obstruction

• have a family history of polycystic kidney disease and are older than 20

• have a GFR of less than 30 ml/min/1.73 m² (GFR category G4 or G5)

• are considered by a nephrologist to need a renal biopsy. [2008, amended 2014]

Advise adults with a family history of hereditary kidney disease about the implications of an abnormal result before a renal ultrasound scan is arranged for them. [2008]

Define accelerated progression of CKD in adults as:

• a sustained decrease in GFR of 25% or more and a change in GFR category within 12 months or

• a sustained decrease in GFR of 15 ml/min/1.73 m² per year. [2014]

Take the following steps to identify the rate of progression of CKD:

• Obtain a minimum of 3 GFR estimations over a period of not less than 90 days.

• In adults with a new finding of reduced GFR, repeat the GFR within 2 weeks to exclude causes of acute deterioration of GFR. For example, acute kidney injury or starting renin–angiotensin system antagonist therapy. [2008, amended 2014]

Be aware that adults with CKD are at increased risk of progression to end-stage renal disease if they have either of the following:

• a sustained decrease in GFR of 25% or more over 12 months or

• a sustained decrease in GFR of 15 ml/min/1.73 m² or more over 12 months. [2008, amended 2014]

When assessing CKD progression, extrapolate the current rate of decline of GFR and take this into account when planning intervention strategies, particularly if it suggests that the person might need renal replacement therapy in their lifetime. [2008, amended 2014]

Work with adults who have any of the following risk factors for CKD progression to optimise their health:

• cardiovascular disease

• proteinuria

• previous episode of acute kidney injury

• hypertension

• diabetes

• smoking

• African, African-Caribbean or Asian family origin

• chronic use of NSAIDs

• untreated urinary outflow tract obstruction. [2014]

In adults with CKD the chronic use of NSAIDs may be associated with progression and acute use is associated with a reversible decrease in GFR. Exercise caution when giving NSAIDs to people with CKD over prolonged periods of time. Monitor the effects on GFR, particularly in people with a low baseline GFR and/or in the presence of other risks for progression. [2008]

Encourage adults with CKD to take exercise, achieve a healthy weight and stop smoking. [2008]

Ensure that systems are in place to:

• inform adults with CKD (and their family members or carers, as appropriate) of their diagnosis

• enable adults with CKD (and their family members or carers, as appropriate) to share in decision making about their care

• support self-management (this includes providing information about blood pressure, smoking cessation, exercise, diet and medicines) and enable adults with CKD to make informed choices. [2014]

Give adults access to their medical data (including diagnosis, comorbidities, test results, treatments and correspondence) through information systems, such as Renal PatientView, to encourage and help them to self-manage their CKD. [2014]

Give adults with CKD and their family members or carers (as appropriate) information about their 5-year risk of needing renal replacement therapy (measured using the 4-variable Kidney Failure Risk Equation).

Follow NICE's guideline on shared decision making when communicating risk. [2021]

Use every day, jargon-free language to communicate information on risk. If technical and medical terms are used, explain them clearly. [2021]

Set aside enough time during the consultation to give information on risk assessment and to answer any questions. Arrange another appointment for more discussion if this is needed. [2021]

Document the discussion on risk assessment and any decisions the person makes. [2021]

Refer adults with CKD for specialist assessment (taking into account their wishes and comorbidities) if they have any of the following:

• a 5-year risk of needing renal replacement therapy of greater than 5% (measured using the 4-variable Kidney Failure Risk Equation)

• an ACR of 70 mg/mmol or more, unless known to be caused by diabetes and already appropriately treated (see recommendations 1.6.6 and 1.6.7)

• an ACR of more than 30 mg/mmol (ACR category A3), together with haematuria

• a sustained decrease in eGFR of 25% or more and a change in eGFR category within 12 months

• a sustained decrease in eGFR of 15 ml/min/1.73 m² or more per year

• hypertension that remains poorly controlled (above the person's individual target) despite the use of at least 4 antihypertensive medicines at therapeutic doses (see also NICE's guideline on hypertension in adults)

• known or suspected rare or genetic causes of CKD

• suspected renal artery stenosis. [2021]

Refer children and young people with CKD for specialist assessment if they have any of the following:

• an ACR of 3 mg/mmol or more, confirmed on a repeat early morning urine sample

• haematuria

• any decrease in eGFR

• hypertension

• known or suspected rare or genetic causes of CKD

• suspected renal artery stenosis

• renal outflow obstruction. [2021]

Consider discussing management with a specialist by letter, email, telephone, or virtual meeting, if there are concerns but the person with CKD does not need to see a specialist. [2021]

Refer people with CKD and renal outflow obstruction to urological services, unless urgent treatment is needed (for example, for hyperkalaemia, severe uraemia, acidosis or fluid overload). [2021]

After referral:

• Agree, document and date a care plan with the person with CKD or their family member or carer (as appropriate). Follow:

  • the recommendations on patient views and preferences in NICE's guideline on patient experience in adult NHS services

  • NICE's guideline on shared decision making.

• Consider routine follow up at the GP surgery or with a paediatrician rather than in a specialist clinic.

• Specify criteria for future referral and re-referral if GP follow up is agreed. For children and young people, these criteria should be agreed between the GP and secondary care services. [2021]

In adults with CKD and an ACR under 70 mg/mmol, aim for a clinic systolic blood pressure below 140 mmHg (target range 120 to 139 mmHg) and a clinic diastolic blood pressure below 90 mmHg. [2021]

In adults with CKD and an ACR of 70 mg/mmol or more, aim for a clinic systolic blood pressure below 130 mmHg (target range 120 to 129 mmHg) and a clinic diastolic blood pressure below 80 mmHg. [2021]

In children and young people with CKD and an ACR of 70 mg/mol or more, aim for a clinic systolic blood pressure below the 50th percentile for height. [2021]

Follow the recommendations on treating hypertension in NICE's guideline on hypertension for adults with CKD, hypertension and an ACR of 30 mg/mmol or less (ACR categories A1 and A2). [2014, amended 2021]

Offer an angiotensin-receptor blocker (ARB) or an angiotensin-converting enzyme (ACE) inhibitor (titrated to the highest licensed dose that the person can tolerate) to adults, children and young people with CKD who have hypertension and an ACR over 30 mg/mmol (ACR category A3 or above). [2021]

For adults with CKD and diabetes (type 1 or type 2) offer an ARB or an ACE inhibitor (titrated to the highest licensed dose that the person can tolerate) if ACR is 3 mg/mmol or more. [2021]

For guidance on SGLT2 inhibitors for adults with CKD and type 2 diabetes, see chronic kidney disease in NICE's guideline on type 2 diabetes in adults. [2021]

For adults with CKD but without diabetes:

• refer for nephrology assessment and offer an ARB or an ACE inhibitor (titrated to the highest licensed dose that they can tolerate), if ACR is 70 mg/mmol or more

• monitor in line with recommendations 1.3.1 and 1.3.4 if ACR is above 30 but below 70 mg/mmol; consider discussing with a nephrologist if eGFR declines or ACR increases. [2021]

For SGLT2 inhibitors recommended as options in NICE technology appraisal guidance as an add-on to optimised standard care for adults with CKD, see the guidance on:

• empagliflozin (TA942, 2023)

• dapagliflozin (TA775, 2022).

For children and young people with CKD and diabetes (type 1 or 2), offer an ARB or an ACE inhibitor (titrated to the highest licensed dose that they can tolerate) if ACR is 3 mg/mmol or more. [2021]

For children and young people with CKD but without diabetes:

• offer an ARB or an ACE inhibitor if ACR (titrated to the highest licensed dose that they can tolerate) is 70 mg/mol or more

• monitor in line with recommendations 1.3.1 and 1.3.4 if ACR is above 30 but below 70 mg/mmol; consider discussing with a nephrologist if eGFR declines or ACR increases. [2021]

When offering medicines to lower proteinuria to people with frailty, comorbidities or who are taking many other prescribed medicines, follow the recommendations in NICE's guideline on medicines optimisation to ensure the best possible outcomes. Seek specialist advice if needed, for example from a consultant in care of the elderly, or from a kidney physician if the person asks about contraception. [2021]

Do not offer a combination of renin–angiotensin system antagonists to adults with CKD. [2014]

Explain to adults with CKD (and their family members or carers, as appropriate) who are prescribed renin–angiotensin system antagonists about the importance of:

• achieving the optimal tolerated dose of renin–angiotensin system antagonists and

• monitoring eGFR and serum potassium in achieving this safely. [2008]

Measure serum potassium concentrations and estimate the GFR before starting renin–angiotensin system antagonists in people with CKD. Repeat these measurements between 1 and 2 weeks after starting renin–angiotensin system antagonists and after each dose increase. [2008]

Do not routinely offer a renin–angiotensin system antagonist to adults with CKD if their pretreatment serum potassium concentration is greater than 5.0 mmol/litre. [2008, amended 2014]

If an adult cannot use renin–angiotensin system antagonists because of hyperkalaemia:

• assess for and treat any other factors that promote hyperkalaemia and

• recheck serum potassium concentration. [2008]

Be aware that more frequent monitoring of serum potassium concentration may be needed if medicines known to promote hyperkalaemia are prescribed for use in people alongside renin–angiotensin system antagonists. [2008]

Stop renin–angiotensin system antagonists in adults if the serum potassium concentration increases to 6.0 mmol/litre or more and other medicines known to promote hyperkalaemia have been discontinued. [2008]

For medicines recommended as options in NICE technology appraisal guidance for treating persistent hyperkalaemia in some people with categories G3b to G5 CKD, see the guidance on:

• sodium zirconium cyclosilicate (TA599, 2022)

• patiromer (TA623, 2020).

After introducing or increasing the dose of renin–angiotensin system antagonists in adults, do not modify the dose if either:

• the GFR decrease from pretreatment baseline is less than 25% or

• the serum creatinine increase from baseline is less than 30%. [2008]

If there is a decrease in eGFR or increase in serum creatinine after starting or increasing the dose of renin–angiotensin system antagonists, but it is less than 25% (eGFR) or 30% (serum creatinine) of baseline, repeat the test in 1 to 2 weeks. Do not modify the renin–angiotensin system antagonist dose if the change in eGFR is less than 25% or the change in serum creatinine is less than 30%. [2008]

If an adult's eGFR change is 25% or more, or the change in serum creatinine is 30% or more:

• investigate other causes of a deterioration in kidney function, such as volume depletion or concurrent medication (for example, NSAIDs)

• if no other cause for the deterioration in kidney function is found, stop the renin–angiotensin system antagonist or reduce the dose to a previously tolerated lower dose, and add an alternative antihypertensive medication if needed. [2008]

Follow the recommendations in NICE's guideline on cardiovascular disease: risk assessment and reduction, including lipid modification for the use of statins in adults with CKD. [2014]

Offer antiplatelet medicines to adults with CKD for the secondary prevention of cardiovascular disease, but be aware of the increased risk of bleeding. [2014]

For guidance on oral anticoagulants for people with CKD, see NICE's guidelines on atrial fibrillation and venous thromboembolic diseases. [2014, amended 2021]

Consider investigating and managing anaemia in adults, children and young people with CKD if:

• their haemoglobin (Hb) level falls to 110 g/litre or less (or 105 g/litre or less if younger than 2 years) or

• they develop symptoms attributable to anaemia (such as tiredness, shortness of breath, lethargy and palpitations). [2011]

In adults, children and young people with anaemia (see recommendation 1.7.3):

• If eGFR is above 60 ml/min/1.73 m², investigate other causes of anaemia as it is unlikely to be caused by CKD.

• If eGFR is between 30 and 60 ml/min/1.73 m²:

  • investigate other causes of anaemia, but

  • use clinical judgement to decide how extensive this investigation should be, because the anaemia may be caused by CKD.

• If eGFR is below 30 ml/min/1.73 m², think about other causes of anaemia but note that anaemia is often caused by CKD. [2021]

Carry out testing to diagnose iron deficiency and determine potential responsiveness to iron therapy and long‑term iron requirements every 3 months (every 1 to 3 months for people having haemodialysis).

• Use percentage of hypochromic red blood cells (% HRC; more than 6%), but only if processing of blood sample is possible within 6 hours.

• If using percentage of hypochromic red blood cells is not possible, use reticulocyte Hb content (CHr; less than 29 pg) or equivalent tests – for example, reticulocyte Hb equivalent.

• If these tests are not available or the person has thalassaemia or thalassaemia trait, use a combination of transferrin saturation (less than 20%) and serum ferritin measurement (less than 100 micrograms/litre). [2015]

Do not request transferrin saturation or serum ferritin measurement alone to assess iron deficiency status in people with anaemia of CKD. [2015]

Do not routinely measure erythropoietin levels for the diagnosis or management of anaemia in people with anaemia of CKD. [2006]

ESA (erythropoietic stimulating agent) therapy should not be started in the presence of absolute iron deficiency without also managing the iron deficiency. [2006]

In adults, children and young people treated with iron, serum ferritin levels should not rise above 800 micrograms/litre. In order to prevent this, review the dose of iron when serum ferritin levels reach 500 micrograms/litre. [2006]

Discuss the pros and cons of a trial of anaemia management with the person with anaemia of CKD, and their families and carers if agreed. [2006]

ESAs need not be administered if the presence of comorbidities, or the prognosis, is likely to negate the benefits of correcting the anaemia. [2006]

Start a trial of anaemia correction when there is uncertainty over whether the presence of comorbidities, or the prognosis, would negate benefit from correcting the anaemia with ESAs. [2006]

If a trial of ESA therapy is carried out, assess the effectiveness of the trial after an agreed interval. Agree with the person with anaemia of CKD (and their families and carers, if appropriate) whether or not to continue ESA therapy. [2006]

Review treatment in all people started on ESA therapy after an agreed interval to decide whether or not to continue using ESAs. [2006]

Roxadustat is recommended as an option in NICE technology appraisal guidance for treating symptomatic anaemia in adults with stage 3 to 5 CKD and no iron deficiency who are not on dialysis. For full details, see the guidance on roxadustat (TA807, 2022).

Do not prescribe supplements of vitamin C, folic acid or carnitine as adjuvants specifically for the treatment of anaemia of CKD. [2006]

Do not use androgens to treat anaemia in people with anaemia of CKD. [2006]

Treat clinically relevant secondary hyperparathyroidism in adults, children and young people with CKD to improve the management of the anaemia. [2006]

Cinacalcet is recommended as an option in NICE technology appraisal guidance for treating refractory secondary hyperparathyroidism in some people with end-stage renal disease on maintenance dialysis. For full details, see the guidance on cinacalcet (TA117, 2007).

Etelcalcetide is recommended as an option in NICE technology appraisal guidance for treating secondary hyperparathyroidism in adults with CKD on haemodialysis if treatment with a calcimimetic is indicated but cinacalcet is not suitable. For full details, see the guidance on etelcalcetide (TA448, 2017).

Give adults, children and young people offered ESA therapy and their GPs information about why ESA therapy is needed, how it works and what benefits and side effects may be experienced. [2006]

When managing the treatment of anaemia of CKD, there should be agreed protocols defining roles and responsibilities of healthcare professionals in primary and secondary care. [2006]

Explain to people receiving ESA therapy about the importance of concordance with therapy and the consequences of poor adherence. [2006]

When prescribing ESA therapy, take into account the person's preferences about supervised‑ or self‑administration, dose frequency, pain on injection, method of supplying ESA and storage. [2006]

In order for people to self‑administer their ESA in a way that is clinically effective and safe, make arrangements to provide ready, reasonable and uninterrupted access to supplies. [2006]

Offer culturally and age‑appropriate patient education programmes to all adults, children and young people diagnosed with anaemia of CKD (and their families and carers). These should be repeated as requested, and according to the person's changing circumstances. They should include the following key areas:

• Practical information about how anaemia of CKD is managed.

• Knowledge (for example, about symptoms, iron management, causes of anaemia, associated medications, phases of treatment).

• Professional support (for example, contact information, community services, continuity of care, monitoring, feedback on progress of results).

• Lifestyle (for example, diet, physical exercise, maintaining normality, meeting other people with the condition).

• Adaptation to chronic disease (for example, previous information and expectations, resolution of symptoms). [2006]

Offer treatment with ESAs to adults, children and young people with anaemia of CKD who are likely to benefit in terms of quality of life and physical function. [2006]

Avoid blood transfusions if possible in people with anaemia of CKD in whom kidney transplant is a treatment option. [2006]

If a transfusion is indicated clinically in a person with anaemia of CKD, follow NICE's guideline on blood transfusion. [2006, amended 2015]

Discuss the choice of ESA with the person with anaemia of CKD when starting treatment and at subsequent review, taking into account:

• the person's dialysis status

• the route of administration

• the local availability of ESAs

• the lack of evidence comparing the efficacy of ESAs. [2006]

Ensure people with anaemia of CKD have access to a designated contact person or people who have principal responsibility for their anaemia management and who have skills in the following activities:

• Monitoring and managing a caseload in line with locally agreed protocols.

• Providing information, education and support to empower people and their families and carers to participate in their care.

• Coordinating an anaemia service for people with CKD, working between secondary and primary care and providing a single point of contact, to ensure people receive a seamless service of the highest standard.

• Prescribing medicines related to anaemia management and monitoring their effectiveness. [2006]

Agree a treatment plan between the prescriber and the person with anaemia of CKD that ensures ESA therapy is clinically effective, consistent and safe. The plan should be person‑centred and include:

• continuity of medicine supply

• flexibility of where the medicine is delivered and administered

• the person's lifestyle and preferences

• cost of medicine supply

• desire for self‑care if appropriate

• regular review of the plan in light of changing needs. [2006]

Agree the route of administration of ESAs between the person with anaemia of CKD and the prescriber, and revise as appropriate. Take into account the following factors:

• patient population (for example, people having haemodialysis)

• pain of injection

• frequency of administration

• the person's lifestyle and preferences

• efficacy (for example, subcutaneous compared with intravenous administration, or long‑acting compared with short‑acting preparations)

• cost of medicine supply. [2006]

The prescriber should take into account that when using short‑acting ESAs, subcutaneous injection allows the use of lower doses of medicines than intravenous administration. [2006]

When correcting anaemia of CKD, the dose and frequency of ESA should be:

• determined by the duration of action and route of administration of the ESA

• adjusted to keep the rate of Hb increase between 10 and 20 g/litre/month. [2006]

When determining individual aspirational Hb ranges for people with anaemia of CKD, take into account:

• their preferences

• symptoms and comorbidities

• the necessary treatment. [2011]

Do not routinely correct Hb to normal levels with ESAs in adults, children and young people with anaemia of CKD.

• Typically maintain the aspirational Hb range between 100 and 120 g/litre for adults, young people and children aged 2 years and over, and between 95 and 115 g/litre for children under 2 years, reflecting the lower normal range in that age group.

• To keep the Hb level within the aspirational range, do not wait until Hb levels are outside the aspirational range before adjusting treatment (for example, take action when Hb levels are within 5 g/litre of the range's limits).
  
  Follow the MHRA safety advice on recombinant human erythropoietins, particularly the advice to avoid Hb levels above 120 g/litre because of the increased risk of death and serious adverse cardiovascular events in people with CKD. People should have close monitoring to ensure that the lowest approved dose of ESA is used to provide adequate control of the anaemia symptoms. [2021]

Consider accepting Hb levels below the agreed aspirational range if:

• high doses of ESAs are needed to achieve the aspirational range or

• the aspirational range is not achieved despite escalating ESA doses.
  
  High doses are more than 175 IU/kg per week for people having haemodialysis; more than 125 IU/kg per week for people having peritoneal dialysis; more than 100 IU/kg per week for people not having dialysis. [2011]

Do not use age alone to determine treatment of anaemia of CKD. [2006]

Optimise iron status before or at the same time as starting ESAs and during maintenance treatment with ESAs. [2006, amended 2011]

Use of ACE inhibitors or angiotensin type II receptor antagonists is not precluded, but if they are used, an increase in ESA therapy should be considered. [2006]

Take into account Hb measurements when determining the dose and frequency of ESA administration.

• Investigate the cause of an unexpected change in Hb level (that is, intercurrent illness or bleeding) to enable intervention and optimise iron status.

• Increase or decrease ESA dose and/or frequency when Hb measurements fall outside action thresholds (usually below 105 g/litre or above 115 g/litre), or for example when the rate of change of Hb suggests an established trend (for example, greater than 10 g/litre/month). [2006, amended 2011]

Offer iron therapy to adults, children and young people with anaemia of CKD who are receiving ESAs to achieve:

• percentage of hypochromic red blood cells less than 6% (unless ferritin is greater than 800 micrograms/litre)

• reticulocyte Hb count or equivalent tests above 29 pg (unless serum ferritin is greater than 800 micrograms/litre).
  
  If these tests are not available or the person has thalassaemia or thalassaemia trait, iron therapy should maintain transferrin saturation greater than 20% and serum ferritin level greater than 100 micrograms/litre (unless serum ferritin is greater than 800 micrograms/litre).
  
  Most adults will need 500 to 1,000 mg of iron (equivalent doses for children) in a single or divided dose depending on the preparation. Intravenous iron should be administered in a setting with facilities for resuscitation. [2015]
  
  In August 2021, this was an off-label use of intravenous iron products for some ages of children and young people. See NICE's information on prescribing medicines.

Offer a high-dose intravenous iron regimen to adults, children and young people with stage 5 CKD on in-centre (hospital or satellite unit) haemodialysis, if they have iron deficiency (see recommendation 1.7.3).

See table 3 for an example of a high-dose intravenous iron regimen for adults or use a bioequivalent dose of iron. For children and young people, use the maximum dosing regimen in the British National Formulary for Children (BNFc) unless serum ferritin is greater than 800 micrograms/litre when the dose should be withheld.

In August 2021, this was an off-label use of intravenous iron products for some children and young people. See NICE's information on prescribing medicines. [2021]

Once the percentage of hypochromic red blood cells is less than 6%, reticulocyte Hb count or equivalent tests are above 29 pg, or transferrin saturation is greater than 20% and serum ferritin level is greater than 100 micrograms/litre, offer maintenance iron to people with anaemia of CKD who are receiving ESAs.

The dosing regimen will depend on modality, for example people having haemodialysis will need the equivalent of 50 to 60 mg intravenous iron per week (or an equivalent dose in children of 1 mg/kg/week). [2015]

In August 2021, this was an off-label use of intravenous iron products for some ages of children and young people. See NICE's information on prescribing medicines.

Offer iron therapy to adults, children and young people receiving ESA maintenance therapy to keep their:

• percentage of hypochromic red blood cells less than 6% (unless serum ferritin is greater than 800 micrograms/litre)

• reticulocyte Hb count or equivalent tests above 29 pg (unless serum ferritin is greater than 800 micrograms/litre)

• transferrin saturation level above 20% and serum ferritin level above 100 micrograms/litre (unless serum ferritin is greater than 800 micrograms/litre).
  
  The marker of iron status should be monitored every 1 to 3 months in people having haemodialysis.
  
  In people who are pre-dialysis or receiving peritoneal dialysis, levels are typically monitored every 3 months. If these people have a normal full blood count there is little benefit in checking iron status. [2015]
  
  In August 2021, this was an off-label use of intravenous iron products for some ages of children and young people. See NICE's information on prescribing medicines.

Offer iron therapy to adults, children and young people with anaemia of CKD who are iron deficient and who are not receiving ESA therapy, before discussing ESA therapy. (In August 2021, this was an off-label use of intravenous iron products for some ages of children and young people. See NICE's information on prescribing medicines).

• Discuss the risks and benefits of treatment options. Take into account the person's choice.

• For people who are not having haemodialysis, consider a trial of oral iron before offering intravenous iron therapy. If they are intolerant of oral iron or target Hb levels are not reached within 3 months (see recommendation 1.9.11), offer intravenous iron therapy.

• For people who are having haemodialysis, offer intravenous iron therapy. Offer oral iron therapy to people who are having haemodialysis only if:

  • intravenous iron therapy is contraindicated or

  • the person chooses not to have intravenous iron therapy after discussing the relative efficacy and side effects of oral and intravenous iron therapy. [2015]

Discuss the results of the iron therapy with the person or, if appropriate, with their family or carers and offer ESA therapy if needed (see recommendation 1.9.1). [2015]

Offer iron therapy to adults, children and young people with anaemia of CKD who are iron deficient and who are receiving ESA therapy. (In August 2021, this was an off-label use of intravenous iron products for some ages of children and young people. See NICE's information on prescribing medicines).

• Discuss the risks and benefits of treatment options. Take into account the person's choice.

• For adults and young people, offer intravenous iron therapy.

• For children who are having haemodialysis, offer intravenous iron therapy.

• For children who are not having haemodialysis, consider oral iron. If the child is intolerant of oral iron or target Hb levels are not reached within 3 months (see recommendation 1.9.11), offer intravenous iron therapy. [2015]

Offer oral iron therapy to adults and young people who are receiving ESA therapy only if:

• intravenous iron therapy is contraindicated or

• the person chooses not to have intravenous iron therapy after discussing the relative efficacy and side effects of oral and intravenous iron therapy. [2015]

When offering intravenous iron therapy to people not having haemodialysis, consider high‑dose low‑frequency intravenous iron as the treatment of choice for adults and young people when trying to achieve iron repletion. Take into account all of the following:

• preferences of the person with anaemia of CKD or, if appropriate, their family or carers

• nursing and administration costs

• cost of local medicine supply

• provision of resuscitation facilities.
  
  High-dose and low-frequency iron is a maximum of 2 infusions, with a minimum of 500 mg of iron in each infusion for adults. Low dose and high frequency is more than 2 infusions with 100 mg to 200 mg of iron in each infusion for adults. [2015]
  
  In August 2021, this was an off-label use of intravenous iron products for some ages of children and young people. See NICE's information on prescribing medicines.

Do not check iron levels earlier than 1 week after administering intravenous iron in adults, children and young people with anaemia of CKD. The length of time to monitoring of iron status is dependent on the product used and the amount of iron given. [2006]

Carry out routine monitoring of iron stores to prevent iron overload using serum ferritin at intervals of 1 to 3 months. [2006, amended 2015]

In adults, children and young people with anaemia of CKD, monitor Hb:

• every 2 to 4 weeks in the induction phase of ESA therapy

• every 1 to 3 months in the maintenance phase of ESA therapy

• more frequently after an ESA dose adjustment

• in a clinical setting chosen in discussion with the person, taking into account their convenience and local healthcare systems. [2006]

After other causes of anaemia, such as intercurrent illness or chronic blood loss have been excluded, regard people with anaemia of CKD as resistant to ESAs when:

• an aspirational Hb range is not achieved despite treatment with 300 IU/kg/week or more of subcutaneous epoetin or 450 IU/kg/week or more of intravenous epoetin or 1.5 micrograms/kg/week of darbepoetin or

• there is a continued need for the administration of high doses of ESAs to maintain the aspirational Hb range. [2006]

In people with CKD, pure red cell aplasia (PRCA) is indicated by a low reticulocyte count, together with anaemia and the presence of neutralising antibodies. Confirm PRCA by the presence of anti‑erythropoietin antibodies together with a lack of pro‑erythroid progenitor cells in the bone marrow. [2006]

In people with anaemia of CKD, aluminium toxicity should be considered as a potential cause of a reduced response to ESAs after other causes, such as intercurrent illness and chronic blood loss, have been excluded. [2006]

If aluminium toxicity is suspected in an adult, child or young person with anaemia of CKD having haemodialysis, perform a desferrioxamine test and review the management of their condition accordingly. [2006]

Consider specialist referral for people with ESA‑induced PRCA. [2006, amended 2011]

Consider referring adults, children and young people with ESA resistance to a haematology service, particularly if an underlying haematological disorder is suspected. [2015]

Evaluate and discuss the risks and benefits of red cell transfusion with the person or, if appropriate, with their family or carers. [2015]

Take into account the person's symptoms, quality of life, underlying conditions and the chance of a future successful kidney transplant, in addition to Hb levels, when thinking about the need for red cell transfusion. [2015]

Review the rate of red cell transfusion and consider a trial period of stopping ESA in people who have ESA resistance (typically on haemodialysis and on high‑dose ESA) and are having frequent transfusions when:

• all reversible causes of ESA resistance have been taken into account and excluded and

• the person's condition is otherwise stable (without intercurrent illness such as infection) and

• the person is receiving adequate dialysis.
  
  Review the rate of red cell transfusion between 1 and 3 months after stopping ESA therapy. If the rate of transfusion has increased, consider restarting ESA therapy. [2015]

A specialist renal dietitian, supported by healthcare professionals with the necessary skills and competencies, should carry out a dietary assessment and give individualised information and advice on dietary phosphate management. [2013]

Tailor advice on dietary phosphate management to the person's learning needs and preferences, rather than using a generalised or complex multicomponent programme of delivery. [2013]

Give information about controlling intake of phosphate-rich foods (in particular, foods with a high phosphate content per gram of protein, as well as food and drinks with high levels of phosphate additives) to control serum phosphate, while avoiding malnutrition by maintaining a protein intake at or above the minimum recommended level. For people on dialysis, take into account possible dialysate protein losses. [2013]

If a nutritional supplement is needed to maintain protein intake in children and young people with hyperphosphataemia, offer a supplement with a lower phosphate content, taking into account the person's preference and other nutritional requirements. [2013]

Before starting phosphate binders for adults, children and young people with CKD stage 4 or 5, optimise:

• diet (see recommendations 1.4.7 to 1.4.9 for adults)

• dialysis, for people who are having this. [2021]

When offering a phosphate binder, explain to them and their family members or carers (as appropriate):

• the reason for offering phosphate binders

• the risks if they are not taken

• the side effects linked to phosphate binders

• when and how they have to be taken (depending on the type of binder), including the exact timing (before, with or after food) and the need to take them with food containing phosphate (including, for example, high-protein snacks). [2021]

Take into account the person's preferences on phosphate binders. [2021]

If the person has problems taking the first phosphate binder offered, consider switching to the next recommended one (see recommendations 1.11.9 to 1.11.15). [2021]

Offer children and young people with CKD stage 4 or 5 and hyperphosphataemia a calcium-based phosphate binder to control serum phosphate levels. [2021]

In August 2021, this was an off-label use of some calcium-based phosphate binders in people not on dialysis. See NICE's information on prescribing medicines.

If serum calcium increases towards, or above, the age-adjusted upper normal limit:

• investigate possible causes other than the phosphate binder

• consider reducing the dose of the calcium-based phosphate binder and adding sevelamer carbonate or switching to sevelamer carbonate alone. [2021]
  
  In August 2021, this was an off-label use of sevelamer carbonate. See NICE's information on prescribing medicines.

For all children and young people who are taking more than 1 phosphate binder, titrate the dosage to achieve the best possible control of serum phosphate while keeping serum calcium levels below the upper normal limit. [2021]

At every routine clinical review, assess the person's serum phosphate control, taking into account:

• diet

• whether they are taking the phosphate binders as prescribed

• other relevant factors, such as vitamin D levels, serum parathyroid hormone levels, alkaline phosphatase, serum calcium, medications that might affect serum phosphate, or dialysis. [2021]

Do not routinely measure calcium, phosphate, parathyroid hormone and vitamin D levels in adults with a GFR of 30 ml/min/1.73 m² or more (GFR category G1, G2 or G3). [2008]

Measure serum calcium, phosphate and parathyroid hormone concentrations in adults with a GFR of less than 30 ml/min/1.73 m² (GFR category G4 or G5). Determine the subsequent frequency of testing by the measured values and the clinical circumstances. If doubt exists, seek specialist opinion. [2008]

Offer bisphosphonates if indicated for the prevention and treatment of osteoporosis in adults with a GFR of 30 ml/min/1.73 m² or more (GFR category G1, G2 or G3). [2008]

Consider oral sodium bicarbonate supplementation for adults with both:

• a GFR less than 30 ml/min/1.73 m² (GFR category G4 or G5) and

• a serum bicarbonate concentration of less than 20 mmol/litre. [2014]