Quality standard

Quality statement 1: Identification and monitoring

Quality statement 1: Identification and monitoring

Quality statement

Adults with, or at risk of, chronic kidney disease (CKD) have eGFRcreatinine and albumin:creatinine ratio (ACR) testing at the frequency agreed with their healthcare professional. [2011, updated 2017]

Rationale

Routine monitoring of key markers of kidney function for adults with, or at risk of, CKD will enable earlier diagnosis and early action to reduce the risks of CKD progression, such as cardiovascular disease, end-stage kidney disease and mortality.

Quality measures

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.

Structure

Evidence of local systems that invite adults with, or at risk of, CKD to have eGFRcreatinine and ACR testing.

Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, through local protocols on appointment reminders.

Process

a) Proportion of adults with CKD who had eGFRcreatinine testing in the past year.

Numerator – the number in the denominator who had eGFRcreatinine testing in the past year.

Denominator – the number of adults with CKD.

Data source: CVD Prevent's indicator CVDP006CKD reports the percentage of people aged 18 and over with GP recorded CKD (G3a to G5), with a record of an eGFR test in the preceding 12 months.

b) Proportion of adults with CKD who had ACR testing at the frequency agreed with their healthcare professional.

Numerator – the number in the denominator who had ACR testing at the frequency agreed with their healthcare professional.

Denominator – the number of adults with CKD.

Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from audit of health records. NHS Digital's indicator no longer in QOF (INLIQ) CKD004 reports the percentage of patients on the CKD register whose notes have a record of a urine albumin:creatinine ratio (or protein:creatinine ratio) test in the preceding 12 months.

c) Proportion of adults at risk of CKD who had eGFRcreatinine testing at the frequency agreed with their healthcare professional.

Numerator – the number in the denominator who had eGFRcreatinine testing at the frequency agreed with their healthcare professional.

Denominator – the number of adults at risk of CKD.

Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from audit of health records.

d) Proportion of adults at risk of CKD who had ACR testing at the frequency agreed with their healthcare professional.

Numerator – the number in the denominator who had ACR testing at the agreed frequency.

Denominator – the number of adults at risk of CKD.

Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from audit of health records.

Outcomes

a) Prevalence of undiagnosed CKD.

Data source: NHS Digital's Quality and Outcomes Framework indicator CKD005 reports the prevalence of patients aged 18 or over with CKD with classification of categories G3a to G5 registered at GP practices. Comparing recorded prevalence with expected prevalence estimated using a tool, such as Public Health England's CKD prevalence model, can give an indication of local prevalence of undiagnosed CKD. CVD Prevent's indicator CVDP002CKD reports the percentage of GP registered people aged 18 and over, with 2 low eGFRs with no GP recorded CKD (G3a to G5) and indicator CVDP003CKD reports the percentage of GP registered patents aged 18 and over, where the latest eGFR reading is low with no GP recorded CKD (G3a to G5).

b) Stage of CKD at diagnosis.

Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from audit of health records.

What the quality statement means for different audiences

Service providers (such as general practices and secondary care services, including renal, cardiology, diabetes and rheumatology clinics) ensure that systems are in place to identify adults with, or at risk of, CKD, for example, through computerised or manual searching of medical records, and offer an appointment to discuss with them how frequently they should have eGFRcreatinine and ACR testing. They also have systems in place to offer appointments for testing at the agreed frequency.

Healthcare professionals (such as GPs, nephrologists, cardiologists, diabetologists, rheumatologists, nurses and pharmacists) discuss and agree the frequency of eGFRcreatinine and ACR testing with adults who have, or at risk of, CKD and offer testing at the agreed frequency. They can then agree any appropriate treatment based on the results of testing.

Commissioners ensure that they commission services in which adults with, or at risk of, CKD have eGFRcreatinine and ACR testing at the frequency agreed with their healthcare professional. They might do this by checking that services have systems in place to identify adults with, or at risk of, CKD and offer appointments to discuss and agree the frequency of eGFRcreatinine and ACR testing.

Adults who have, or may be at risk of, CKD discuss and agree with their healthcare professional how often they should have tests to check how well their kidneys are working. They are offered blood and urine tests at the agreed frequency to find out if their CKD is worsening (progressing), or if they have kidney problems. The blood test is at least once a year for adults with CKD. People with CKD are offered information and education relevant to the cause of kidney disease, how advanced it is, any complications they may have and the chances of it getting worse, to help fully understand and make informed choices about treatment. They are also able to get psychological support if needed – for example, support groups, counselling or support from a specialist nurse.

Source guidance

Chronic kidney disease: assessment and management. NICE guideline NG203 (2021), recommendations 1.1.20, 1.1.21, 1.3.1 and 1.3.4

Definitions of terms used in this quality statement

Adults with CKD

CKD is defined as abnormalities of kidney function or structure present for more than 3 months, with implications for health. This includes:

  • all people with markers of kidney damage, including albuminuria (ACR more than 3 mg/mmol), urine sediment abnormalities, electrolyte and other abnormalities due to tubular disorders, abnormalities detected by histology, structural abnormalities detected by imaging or a history of kidney transplantation

  • people with a glomerular filtration rate (GFR) of less than 60 ml/min/1.73 m2 on at least 2 occasions separated by a period of at least 90 days (with or without markers of kidney damage).

[NICE's guideline on chronic kidney disease, terms used in this guideline]

Adults at risk of CKD

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

  • medicines that can adversely affect kidney function, such as calcineurin inhibitors (for example, cyclosporin or tacrolimus), lithium or non-steroidal anti-inflammatory drugs (NSAIDs).

[NICE's guideline on chronic kidney disease, recommendations 1.1.20 and 1.1.21, and expert opinion]

eGFRcreatinine testing

A blood test that estimates glomerular filtration rate (GFR) by measuring serum creatinine. It is used as an estimate of kidney function to identify kidney disease and monitor CKD progression. Clinical laboratories should use the Chronic Kidney Disease Epidemiology Collaboration (CKD‑EPI) creatinine equation to estimate GFRcreatinine, using creatinine assays with calibration traceable to standardised reference material. [Adapted from NICE's guideline on chronic kidney disease, recommendation 1.1.2]

Albumin:creatinine ratio (ACR) testing

A test used to detect and identify protein in the urine, which is a sign of kidney disease, and can be used to assess progression of CKD. [Adapted from NICE's guideline on chronic kidney disease, recommendation 1.1.12, and full guideline]

At the frequency agreed with their healthcare professional

The frequency of monitoring should be discussed and agreed by the person and their healthcare professional. Table 2 in NICE's guideline on chronic kidney disease should be used to guide the frequency of GFR monitoring. Adults with CKD should be seen at least annually and adults at risk of CKD can be seen annually or less often for monitoring of eGFR. ACR does not need to be measured every time eGFR is measured, except when evaluating response to a treatment targeted at reducing proteinuria. Frequency of monitoring is determined by the stability of kidney function and the ACR level, and tailored to the individual according to:

  • the underlying cause of CKD

  • the rate of decline in eGFR or increase in ACR (but be aware that CKD progression is often non-linear)

  • other risk factors, including heart failure, diabetes and hypertension

  • changes to their treatment (such as renin–angiotensin–aldosterone system [RAAS] antagonists, NSAIDs and diuretics)

  • intercurrent illness (for example, acute kidney injury)

  • whether they have chosen conservative management of CKD.

[Adapted from NICE's guideline on chronic kidney disease, recommendations 1.3.1 and 1.3.4, and full guideline]