Chronic kidney disease: assessment and management

Context

Chronic kidney disease (CKD) describes abnormal kidney function or structure. It is common and often occurs with other conditions (such as cardiovascular disease and diabetes). Moderate to severe CKD is also associated with an increased risk of acute kidney injury, falls, frailty and mortality. The risk of developing CKD increases with age.

CKD is usually asymptomatic, but it is detectable, and tests for CKD are simple and 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, CKD is often unrecognised or diagnosed at an advanced stage. Late presentation of people with kidney failure increases morbidity, mortality and associated healthcare costs.

As kidney disease progresses, some coexisting conditions become more common and increase in severity. Hyperphosphataemia is an example of this, occurring because of insufficient filtering of phosphate from the blood by poorly functioning kidneys. This means that a certain amount of the phosphate does not leave the body in the urine, instead remaining in the blood at abnormally high levels.

High serum phosphate levels can directly and indirectly increase parathyroid hormone secretion, leading to the development of secondary hyperparathyroidism. Left untreated, secondary hyperparathyroidism increases morbidity and mortality and may lead to renal bone disease, with people experiencing bone and muscular pain, fracture, bone and joint abnormalities, and vascular and soft tissue calcification.

Many people with CKD or established renal failure also develop associated anaemia. The prevalence of anaemia associated with CKD increases progressively with the stage of CKD, especially when the person reaches stage 4 or 5. Anaemia of CKD contributes significantly to the burden of CKD. However, it is potentially reversible and manageable with appropriate identification and treatment.

The Health Survey for England (2016) found that 13% of adults (16 years and over) had any CKD (stages 1 to 5). The prevalence of stages 3 to 5 was 5% for all adults, rising to 34% in people aged 75 and over. At the end of 2018 there were 826 children and young people and 66,612 adults receiving renal replacement therapy in the UK according to the UK Renal Registry annual report.

Since publication of the previous guidelines, new evidence was identified for several areas. The following areas of the guideline have been updated: