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A persistently high blood sugar level can damage the blood vessels in the kidneys. For more information about kidney disease caused by diabetes, see the topic Diabetic Nephropathy. To learn ways to help control your blood pressure, see the topic High Blood Pressure. If other conditions or diseases are causing kidney damage, such as a blockage obstruction in the urinary tract or long-term use of medicines that can damage the kidneys , you and your doctor will work out a treatment plan.

These medicines are used to reduce protein in the urine and help manage high blood pressure. You can take steps at home to help control your kidney disease. For example:. Your doctor will use blood and urine tests to regularly check how well your kidneys are functioning and whether changes to your treatment plan are needed.

These tests are critical to help monitor your disease. The tests include:. As the disease gets worse, your symptoms—such as fatigue, nausea, and loss of appetite—may occur more often or become more severe. Work with your doctor to create a treatment plan to help control these symptoms. If you develop anemia , you may need to take medicine called human erythropoietin EPO. It helps your body make new red blood cells and may help improve your appetite and general sense of well-being. You may also need an iron supplement if you have an iron deficiency.

If you develop uremic syndrome uremia , you will need to have wastes and fluids removed through dialysis or your kidney replaced through a kidney transplant. When your kidney function has fallen below a certain point, it is called kidney failure. It can cause serious heart, bone, and brain problems and can make you feel very ill. Dialysis is a process that does the work of healthy kidneys by clearing wastes and extra fluid from the body and restoring the proper balance of chemicals electrolytes in the blood.

You may use dialysis for many years, or it may be a short-term measure while you are waiting for a kidney transplant. To learn more about dialysis, see Other Treatment. Kidney transplant is often a better treatment option than dialysis for kidney failure, because it may allow you to live a fairly normal life.

But there are some drawbacks. For example, you will probably need to have dialysis while you wait for a kidney. To learn more about kidney transplants, see Surgery. Making treatment decisions when you are very ill is difficult. It is normal to be fearful and worried about the risks involved. Discuss your concerns with your family and your doctor. It may be helpful to visit the dialysis centre or transplant centre and talk to others who have chosen these options. Hospice palliative care is a kind of care for people who have diseases that don't go away and that often get worse over time.

It is different from care to cure your illness. Hospice palliative care focuses on improving your quality of life—not just in your body but also in your mind and spirit. It can be used at any point in the course of your kidney disease. You can have hospice palliative care along with treatment to cure your illness. You can also have it if treatment to cure your illness no longer seems like a good choice.

Hospice palliative care professionals work with you and your doctor to help manage pain and other symptoms or side effects related to blood pressure, heart disease, diabetes, depression, anxiety, or other conditions. Hospice palliative care can help you sort out your feelings about living with kidney disease and about your treatment choices.

It can help your family better understand your disease and how to support you. If you are interested in hospice palliative care, talk to your doctor. He or she may be able to manage your care or refer you to a doctor who specializes in this type of care. For more information, see the topic Hospice Palliative Care. Chronic kidney disease progresses to kidney failure when damage to the kidneys is so severe that dialysis or a kidney transplant is needed to control symptoms and prevent complications and death. Many people have successful kidney transplants or live for years using dialysis.

But at this point you may wish to talk with your family and doctor about health care and other legal issues that arise near the end of life. A time may come when your goals or the goals of your loved ones may change from treating or curing your disease to maintaining comfort and dignity. You may find it helpful and comforting to state your health care choices in writing with an advance care plan while you are still able to make and communicate these decisions. Think about your treatment options and which kind of treatment will be best for you. You may wish to choose a substitute decision-maker , usually a family member or loved one, to make and carry out decisions about your care if you become unable to speak for yourself.

You also have the option to refuse or stop treatment. For more information, see the topic Care at the End of Life. Chronic kidney disease may sometimes be prevented by controlling the other diseases or factors that can contribute to kidney disease. People who have already developed kidney failure also need to focus on these things to prevent the complications of kidney failure. There are many things you can do at home to slow the progression of chronic kidney disease. Although medicine cannot reverse chronic kidney disease, it is often used to help treat symptoms and complications and to slow further kidney damage.

Most people who have chronic kidney disease have problems with high blood pressure at some time during their disease. Medicines that lower blood pressure help to keep it in a target range and stop any more kidney damage. You may need to try several blood pressure medicines before you find the medicine that controls your blood pressure well without bothersome side effects. Most people need to take a combination of medicines to get the best results.

Your doctor may order blood tests 3 to 5 days after you start or change your medicines. The tests help your doctor make sure that your medicines are working correctly. Medicines may be used to treat symptoms and complications of chronic kidney disease. These medicines include:. Both erythropoietin EPO therapy and iron replacement therapy may also be used during dialysis to treat anemia, which often develops in advanced chronic kidney disease.

Talk with your doctor about what types of immunizations you should have if you have chronic kidney disease, such as flu influenza and pneumococcal vaccines. Also, be sure to discuss medicine precautions. Make sure to tell your doctor about all prescription drugs, over-the-counter drugs, and herbs you are taking.

If you have chronic kidney disease that progresses, you may have the option of a kidney transplant. Most experts agree that it is the best option for people with kidney failure. In general, people who have kidney transplants live longer than people treated with dialysis. You will probably be considered a good candidate if you don't have significant heart, lung, or liver disease or other diseases, such as cancer, which might decrease your life span.

There are some drawbacks. You may have to wait for a kidney to be donated. If so, you will need to have dialysis while you wait. Also, it may be hard to find a good match for your blood and tissue types. Sometimes, even when the match is good, the body rejects the new kidney. After a kidney transplant, you will have to take medicines called immunosuppressants.

These medicines, such as cyclosporine or tacrolimus, help prevent your body from rejecting your new kidney. Even if you take your medicines, there is a chance that your body will reject your new kidney. If this happens, you will have to resume dialysis or have another kidney transplant. The success of the transplant also depends on what kind of donor kidney you are receiving.

The closer the donor kidney matches your genetic makeup, the better the chances that your body will not reject it. For more general information about transplant, see the topic Organ Transplant. A kidney transplant doesn't guarantee that you will live longer than you would have without a new kidney.

Dialysis is a mechanical process that performs the work that healthy kidneys would do. It clears wastes and extra fluid from the body and restores the proper balance of chemicals electrolytes in the blood.

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When chronic kidney disease becomes so severe that your kidneys are no longer working properly, you may need dialysis. You may use dialysis to replace the work of the kidneys for many years. Or dialysis may be a short-term measure while you are waiting for a kidney transplant. The two types of dialysis used to treat severe chronic kidney disease are hemodialysis and peritoneal dialysis. If you have severe chronic kidney disease but have not yet developed kidney failure , talk to your doctor about which type of dialysis would be best for you.

Learning about dialysis predialysis education is an important step in preparing for dialysis. Most dialysis clinics offer predialysis services to help you know about your choices. Author: Healthwise Staff. Medical Review: Anne C. This information does not replace the advice of a doctor. Healthwise, Incorporated disclaims any warranty or liability for your use of this information. Your use of this information means that you agree to the Terms of Use and Privacy Policy.

Learn how we develop our content. To learn more about Healthwise, visit Healthwise. Healthwise, Healthwise for every health decision, and the Healthwise logo are trademarks of Healthwise, Incorporated. British Columbia Specific Information For your kidneys and overall health, it is important that you follow a healthy diet and maintain a healthy weight. Top of the page. Topic Overview Is this topic for you?

Health Tools Health Tools help you make wise health decisions or take action to improve your health. Decision Points focus on key medical care decisions that are important to many health problems. Actionsets are designed to help people take an active role in managing a health condition. Cause The cause of chronic kidney disease isn't always known.

The most common causes of chronic kidney disease are: Diabetes. High blood sugar levels caused by diabetes damage blood vessels in the kidneys.

What Is Chronic Kidney Disease?

If the blood sugar level remains high over many years, this damage gradually reduces the function of the kidneys. High blood pressure hypertension. Uncontrolled high blood pressure damages blood vessels, which can lead to damage in the kidneys. And blood pressure often rises with chronic kidney disease, so high blood pressure may further damage kidney function even when another medical condition initially caused the disease. Other conditions that can damage the kidneys and cause chronic kidney disease include: Kidney diseases and infections, such as polycystic kidney disease , pyelonephritis, glomerulonephritis , or a kidney problem you were born with.

Having a narrowed or blocked renal artery. A renal artery carries blood to the kidneys. Long-term use of medicines that can damage the kidneys. Examples include non-steroidal anti-inflammatory drugs NSAIDs , such as celecoxib and ibuprofen, and certain antibiotics. Symptoms Many people who develop chronic kidney disease don't have symptoms at first. As your kidney function gets worse, you may: Urinate less than normal. Have swelling and weight gain from fluid buildup in your tissues edema. Feel very tired. Lose your appetite or have an unexpected weight loss.

Feel nauseated or vomit. Be either very sleepy or unable to sleep. Have headaches, or have trouble thinking clearly. Have a metallic taste in your mouth. Have severe itching. What Happens At first with chronic kidney disease, your kidneys are still able to regulate the balance of fluids, salts, and waste products in your body. Complications of chronic kidney disease Anemia. You may feel weak, have pale skin, and feel tired, because the kidneys can't produce enough of the hormone erythropoietin needed to make new red blood cells.

Electrolyte imbalance. When the kidneys can't filter out certain chemicals, such as potassium, phosphate, and acids, you may have an irregular heartbeat, muscle weakness, and other problems. Uremic syndrome. You may be tired, have nausea and vomiting, not have an appetite, or not be able to sleep when substances build up in your blood.

The substances can be poisonous toxic if they reach high levels. This syndrome can affect many parts of your body, including the intestines, nerves, and heart. Heart disease. Chronic kidney disease speeds up hardening of the arteries atherosclerosis and increases the risk of stroke, heart attack, and heart failure. Heart disease is the most common cause of death in people with kidney failure.

Bone disease osteodystrophy. Abnormal levels of substances, such as calcium, phosphate, and vitamin D, can lead to bone disease. Fluid buildup edema. As kidney function gets worse, fluids and salt build up in the body. Fluid buildup can lead to heart failure and pulmonary edema. What Increases Your Risk Some of the things that lead to chronic kidney disease are related to your age and your genetic makeup. Things you cannot control The main risk factors for chronic kidney disease are: Age. The kidneys begin to get smaller as people get older. People of African descent and First Nations peoples are more likely to get chronic kidney disease.

Being male. Men have a higher risk for chronic kidney disease than women do. Family history. Family history is a factor in the development of both diabetes and high blood pressure, the major causes of chronic kidney disease. Polycystic kidney disease is one of several inherited diseases that cause kidney failure. Things you may be able to control You may be able to slow the progression of chronic kidney disease and prevent or delay kidney failure by controlling things that increase your risk of kidney damage, such as: High blood pressure , which gradually damages the tiny blood vessels in the kidneys.

A persistently high blood sugar level can damage blood vessels in the kidneys. Over time, kidney damage can progress, and the kidneys may stop working altogether. Eating protein and fats. Eating a diet low in protein and fat may reduce your risk for kidney disease.

Certain medicines. Avoid long-term use of medicines that can damage the kidneys , such as pain relievers called NSAIDs and certain antibiotics. When To Call a Doctor Call or other emergency services if you have chronic kidney disease and you develop: A very slow heart rate less than 50 beats a minute. A very rapid heart rate more than beats a minute. Chest pain or severe shortness of breath.

Severe muscle weakness. Examinations and Tests Tests for chronic kidney disease are vital to help find out: Whether kidney disease happened suddenly or has been happening over a long time. What is causing the kidney damage. Which treatment is best to help slow kidney damage.

How well treatment is working. When to begin dialysis or have a kidney transplant. Tests to check kidney function When kidney function is decreased, substances such as urea, creatinine, and certain electrolytes begin to build up in the blood. A blood creatinine test helps to estimate the glomerular filtration rate GFR by measuring the level of creatinine in your blood. The doctor can use the GFR to regularly check how well the kidneys are working and to stage your kidney disease.

A blood urea nitrogen BUN test measures how much nitrogen from the waste product urea is in your blood. BUN level rises when the kidneys aren't working well enough to remove urea from the blood. A fasting blood glucose test is done to measure your blood sugar. High blood sugar levels damage blood vessels in the kidneys. Blood tests measure levels of waste products and electrolytes in your blood that should be removed by your kidneys. Urinalysis UA and a urine test for microalbumin , or other urine tests, can measure protein in your urine.

Normally there is little or no protein in urine.

Stage 4 of Chronic Kidney Disease (CKD) - DaVita

Tests for anemia If the kidneys don't produce enough of the hormone erythropoietin needed to make red blood cells, anemia can develop. The following tests help monitor anemia: A complete blood count CBC measures the hematocrit and the hemoglobin level. A reticulocyte count shows how many red blood cells are being produced by the bone marrow.

Iron studies show your level of iron, which is needed for erythropoietin to work the way it should. A serum ferritin test measures the protein that binds to iron in your body. Other tests Your doctor may use other tests to monitor kidney function or to find out whether another kidney disease or condition is contributing to reduced kidney function.

An ultrasound of the kidney renal ultrasound helps estimate how long you may have had chronic kidney disease. It also checks whether urine flow from the kidneys is blocked. An ultrasound also may help find causes of kidney disease, such as obstruction or polycystic kidney disease. A duplex Doppler study or angiogram of the kidney may be done to check for problems caused by restricted blood flow renal artery stenosis. A kidney biopsy may help find out the cause of chronic kidney disease. After a kidney transplant, a doctor may use this test if he or she suspects the organ is being rejected by your body.

Early screening for chronic kidney disease Experts recommend screening tests for chronic kidney disease in high-risk groups, such as people with diabetes or high blood pressure. To learn more about screening if you already have diabetes or high blood pressure, see: Diabetic Nephropathy. High Blood Pressure. Treatment Overview The goal of treatment for chronic kidney disease is to prevent or slow further damage to your kidneys. Treatment to control kidney disease Control the disease that's causing the kidney damage One of the most important parts of treatment is to control the disease that is causing kidney damage.

Have a healthy lifestyle You can take steps at home to help control your kidney disease. For example: Follow a diet that is healthy for your kidneys. A dietitian can help you make an eating plan with the right amounts of salt sodium , fluids, and protein. Kidney Disease: Changing Your Diet. Prevention Chronic kidney disease may sometimes be prevented by controlling the other diseases or factors that can contribute to kidney disease. Learn to check your blood pressure at home. Diabetes: Checking Your Blood Sugar. Home Treatment There are many things you can do at home to slow the progression of chronic kidney disease.

Medications Although medicine cannot reverse chronic kidney disease, it is often used to help treat symptoms and complications and to slow further kidney damage. Medicines to treat high blood pressure Most people who have chronic kidney disease have problems with high blood pressure at some time during their disease. Common blood pressure medicines include: ACE inhibitors.

Calcium channel blockers.


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Direct renin inhibitors. Medicines to treat symptoms and complications of chronic kidney disease Medicines may be used to treat symptoms and complications of chronic kidney disease. Numerator — the number in the denominator who had ACR testing at the agreed frequency. Service providers general practices and secondary care services, such as 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 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. 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 be able to get psychological support if needed — for example, support groups, counselling or support from a specialist nurse. CKD is defined as abnormalities of kidney function or structure present for more than 3 months, with implications for health.

This includes:. 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. 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. The frequency of monitoring should be discussed and agreed by the person and their healthcare professional. 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:. Blood pressure control This quality statement is taken from the chronic kidney disease in adults quality standard. Adults with chronic kidney disease CKD have their blood pressure maintained within the recommended range. People with CKD are at a higher risk of high blood pressure. Maintaining blood pressure within a target range reduces the risk of cardiovascular disease, CKD progression and mortality.

Data source: Local data collection, for example, service specifications. Numerator — the number in the denominator whose systolic blood pressure is between — mmHg and their diastolic blood pressure below 90 mmHg.

Topic Contents

Numerator — the number in the denominator whose systolic blood pressure is between — mmHg and their diastolic blood pressure below 80 mmHg. The UK Renal Registry collects data on comorbidities of renal patients, including angina, heart failure and atrial fibrillation. The UK Renal Registry collects data on the cause of death of renal patients. Service providers general practices and secondary care services ensure that systems are in place for adults with CKD to have their blood pressure maintained within the recommended range.

This might involve having the equipment to take a blood pressure reading, using clinical IT systems to compare patients to the recommended range when entering a blood pressure reading, or flagging when patients need a blood pressure reading. Healthcare professionals GPs, nephrologists, nurses and pharmacists monitor the blood pressure of adults with CKD and are aware of the recommended ranges.

They support people to keep their blood pressure within the recommended range, for example, by starting or adjusting treatment, or advising on lifestyle changes. Commissioners clinical commissioning groups and NHS England ensure that they commission services in which adults with CKD have their blood pressure maintained within the recommended range. They work with service providers to ensure that adults with CKD are identified, and have a blood pressure reading and any necessary support to maintain it within the recommended range. Adults with CKD are supported to keep their blood pressure at a healthy level.

If it is too high, their healthcare professional might offer medicine, or change the medicine they are taking, or suggest lifestyle changes, to help to control it. Statins for people with CKD This quality statement is taken from the chronic kidney disease in adults quality standard. After discussing the risks and benefits of starting statin therapy with a healthcare professional, adults with CKD may choose statin therapy as an appropriate treatment to reduce their risk of first CVD events, or of future CVD events in adults who have already had an event, such as a heart attack or stroke. Atorvastatin 20 mg is recommended as the preferred initial high-intensity statin because it is clinically and cost effective for the primary and secondary prevention of CVD.

Service providers general practices and secondary care services, such as renal, cardiology, diabetes and rheumatology clinics ensure that systems are in place for adults with CKD to be offered atorvastatin 20 mg. For example, this may be done through incorporating treatment algorithms into software applications to provide users with patient-specific recommendations on treatment.

Health professionals GPs, nephrologists, cardiologists, diabetologists, rheumatologists, nurses and pharmacists check whether adults with CKD are taking a statin, and discuss the risks and benefits of starting statin therapy if not. If a person is not able to tolerate atorvastatin 20 mg or reports adverse effects, they discuss alternative options such as stopping the statin or changing the dose or type of statin. Commissioners clinical commissioning groups and NHS England ensure that they commission services in which adults with CKD are offered atorvastatin 20 mg.

Commissioners may do this by seeking evidence of practice through clinical audits. Adults with CKD are at a higher risk of heart attacks and strokes. To help reduce the risk they are offered a type of medicine called a statin, which lowers the level of cholesterol sometimes called lipids in the blood. If their cholesterol level does not decrease enough, they may change to a higher dose. If the statin causes any side effects, their doctor might ask them to stop taking it for a while to check that they are caused by the statin.

Their doctor might discuss reducing the dose or changing to a different statin. Effective interventions library. NICE has produced resources to help implement its guidance on:. Renal replacement therapy and conservative management. Chronic kidney disease in adults: assessment and management.

Sodium zirconium cyclosilicate for treating hyperkalaemia. Immunosuppressive therapy for kidney transplant in children and young people. Immunosuppressive therapy for kidney transplant in adults. Etelcalcetide for treating secondary hyperparathyroidism. Robot-assisted kidney transplant. Laparoscopic insertion of peritoneal dialysis catheter. Laparoscopic live donor simple nephrectomy.

Renal replacement therapy services for adults. Chronic kidney disease in adults. NICE has written information for the public on each of the following topics. Machine perfusion and cold static storage of kidneys from donors who have died. Cinacalcet for treating secondary hyperparathyroidism in people with kidney disease who are on dialysis. Laparoscopic insertion of a peritoneal dialysis catheter.

Multiple frequency bioimpedance devices to guide fluid management in people with chronic kidney disease having dialysis. Rationale and impact: coordinating and delivering care Rationale The committee noted that people on RRT experience considerable treatment burden and that strategies should be adopted to reduce this.

There was no evidence on care coordination by a keyworker so the committee recommended the healthcare professional responsible for renal care as a first point of contact. They made a research recommendation on care coordination by a keyworker to inform future guidance. The recommendation on reducing treatment burden standardises and reinforces good practice. Some healthcare professionals may need to change their practice but this would not result in a substantial resource impact. For more information, see evidence review M: coordinating care. When to refer Take into account the individual's wishes and comorbidities when considering referral.

People with CKD in the following groups should normally be referred for specialist assessment:. 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.

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 between the person with CKD or their carer and the healthcare professional , 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.

Rationale and impact: providing contact details Rationale There was limited evidence on the coordination of care but the committee agreed that people should know who to contact with questions about their condition or treatment. This is particularly important when they start or change RRT modalities. Current practice is variable in terms of when a person is given the details of the person responsible for care. This recommendation will ensure that this is done before starting treatment or when switching modalities or to conservative management.

Rationale and impact: providing information and support Rationale The committee used the evidence and their own experience to update the recommendations on information and support from NICE's guideline on peritoneal dialysis CG and to extend these to cover other forms of RRT and conservative management. Key findings related to information being provided well in advance of decisions being needed, multiple formats of information being available, and full information on all modalities being provided.

Information should also be provided on the psychological impact of starting RRT and the decision-making process. The recommendations broadly reflect current practice and therefore are unlikely to have a resource impact. They focus mainly on the principles of information and support rather than on specific interventions.

For more information, see evidence review K: information, education and support. Kidney International Suppl. Rationale and impact: when to assess Rationale Some evidence indicated that earlier referral to nephrology services improved survival on RRT at 90 days. The committee were interested in the timing of referral for assessment for RRT and used their experience to recommend that this should be at least 1 year before RRT is likely to be needed.

They agreed that this would provide time for clinical and psychological preparation for dialysis or pre-emptive transplantation, and give the person, family members and carers enough time to think about the options. The committee acknowledged that there might be possible harms and costs for people who were referred but did not go on to need RRT, but they agreed that these were outweighed by the benefits of early referral for most people. The recommendation generally reflects current practice so there should be no significant change in practice or substantial resource impact to the NHS in England.

For more information, see evidence review E: when to assess for renal replacement therapy. Possible symptoms in people on renal replacement therapy or conservative management Category. Rationale and impact: assessing the condition Rationale The committee recognised that an assessment should involve preparing people for RRT , for example, by explaining the procedures to create vascular access and checking heart function and immunity.

Psychosocial preparation is also important for reducing non-adherence and improving outcomes. They also highlighted the importance of discussing a person's preferences and understanding how decisions on RRT or conservative management are likely to affect a person's everyday life. No evidence was identified on the psychological assessment of transplant recipients or donors.

The committee agreed that there were likely benefits for identifying risk factors for non-adherence or morbidity after the operation. These could include substance misuse, current non-adherence or a previous or current mental health condition. Given the lack of evidence and potential resource impact, the committee agreed that assessment could be considered for specific high-risk groups.

ABCs of Kidney Disease - Treatment Options for Chronic Kidney Disease (CKD)

There was no evidence on cardiac assessment before transplantation. The committee discussed current practice and agreed it is very variable. They therefore decided to make a research recommendation to inform future practice. Psychological assessment in people at high risk of non-adherence or morbidity is current practice in many areas. The recommendation is likely to lead to better targeting of psychological assessment in other areas.

The recommendation was not considered likely to have a substantial resource impact overall. For more information, see evidence review F: how to assess people for renal replacement therapy. Rationale and impact: joint decisions about treatment options Rationale People who are likely to need RRT should be supported to make decisions about treatment options, including conservative management. There was no evidence of differential benefits or harms in any specific group of people and the committee agreed that the decision needs to be based on individual factors such as frailty, cognitive impairment and multimorbidity and patient preference.

The recommendation to consider HDF over HD for in-centre dialysis may affect resource use in areas where this is a change in practice. There are likely to be additional costs relating to consumables and water consumption with HDF compared with HD, but these may be partly offset by reduced use of erythropoietin-stimulating agent. There may be additional costs for machines where HDF-capable machines are not currently used.


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However, most centres already have some HDF-capable machines. This will enable them to accommodate any initial increased demand for HDF. Provision can be expanded if demand increases within the usual replacement cycles. These additional costs may result in a substantial resource impact to the NHS in England overall.

However, this is uncertain as it is not possible to accurately predict how widely additional use of HDF will be considered. Although use of different RRT modalities and conservative management varies between areas, other recommendations reinforce current good practice to offer people a choice of modalities and settings, and conservative management, and so are not expected to have a substantial resource impact. The committee agreed that people are often not offered regular opportunities to discuss the option of switching treatment modality or stopping RRT and so this may be a change in practice in many areas.

However, these discussions could form part of current patient reviews and so would not mean a difference in resource use. More regular discussions may lead to more people switching or stopping RRT but this is not expected to result in a substantial resource impact overall. For more information, see evidence review B: modalities of renal replacement therapy. Rationale and impact: transplantation Rationale Evidence showed that if RRT is chosen, transplantation offers a clear advantage over dialysis in terms of extending life. This benefit was observed in each age group. In the committee's experience, quality of life and hospitalisation are also likely to be improved by transplantation.

However, the individual factors that affect the risks and benefits of transplantation, for example, comorbidities, should be discussed. There was no evidence on cost effectiveness but the committee considered transplantation likely to have a lower cost over the long term due to the cost of avoiding dialysis. The committee agreed to recommend pre-emptive transplantation with a living donor or, if this is not an option, a transplant from a deceased donor.

The committee noted that the only available evidence suggested that people with a BMI greater than 30 benefited from transplant as opposed to dialysis to a similar degree as people with a BMI of 30 or under, in terms of mortality. The committee agreed to recommend that healthcare professionals do not exclude people from transplantation based on BMI alone.

Rationale and impact: dialysis options Rationale Choice of dialysis modalities Limited evidence showed that if a transplant is not possible, peritoneal dialysis and HD offered similar benefits and equivalent harms. There was uncertainty about the differences in costs between peritoneal dialysis and HD due to uncertainty in current UK dialysis costs and transport costs. There was no evidence comparing HDF and peritoneal dialysis. Peritoneal dialysis should be considered for children under 2 years due to difficulties with vascular access and extracorporeal blood volume.

There is uncertainty in current UK dialysis costs but they may be lower at home. The committee acknowledged that these treatments can have very different effects on lifestyle and recommended patient choice. Evidence suggested that in-centre HDF was more effective than in-centre HD and was cost effective so the committee agreed that HDF rather than HD should be recommended when dialysis was in centre. The committee noted that HD may be done more frequently at home than in centre.

The benefits of HDF are unknown in people who dialyse more frequently. There was no evidence on the efficacy of HDF at home. The committee was aware that some centres offer home HDF, although some people opt for transportable dialysis machines which cannot do HDF currently and these centres also provide home HD. The committee agreed to make a research recommendation on this to inform future guidance. Again the committee acknowledged that these treatments can have very different effects on lifestyle and recommended patient choice.

The committee agreed that people should have regular opportunities to review treatment options. There was not enough evidence to recommend any particular sequence of RRT modalities. The committee agreed that decisions about sequence would mostly be guided by personal circumstances. Rationale and impact: planning treatment Rationale The committee highlighted the importance of discussing with the person the different types of dialysis and their access and the impacts of these on everyday life. Evidence suggested that the best time for creating access for peritoneal dialysis by open surgery is around 2 weeks before starting dialysis.

There was no evidence on the best time for creating other types of peritoneal access so the committee decided to make a research recommendation to inform future guidance. The committee agreed that doing this early around 6 months reduced the need for additional access procedures. However, when a fistula is created early, some people may never need it, for example, because they have a pre-emptive transplant. The committee agreed that the benefits of establishing a fistula around 6 months before starting dialysis, including the cost savings associated with avoiding additional access procedures, were likely to outweigh the potential disadvantages and increased costs associated with unused fistulae.

The committee noted that the precise timing will vary from person to person, depending on the likely success of fistula creation. Evidence showed a benefit of routine ultrasound scanning in terms of reduced failure of AVF. Cost calculations based on the clinical evidence suggested that routine scanning is likely to reduce overall costs because of fewer repeat interventions. The committee agreed to recommend routine ultrasound scanning to determine vascular access sites. The committee noted that there was no evidence to guide the optimum timing of transplant listing and therefore made a research recommendation in this area.

Current practice for creating vascular access is variable. A minimum timing from creation to use of 6 weeks has been suggested — however, the committee agreed that creation around 6 months reflected common practice. The recommendation is not expected to have a significant impact on practice, but should standardise some current variability. It is not expected to have a substantial resource impact to the NHS in England. Current practice for creating peritoneal dialysis access via open surgery is broadly in line with the recommendation that is, 2 weeks before use and so this recommendation is not expected to have a substantial resource impact to the NHS in England.

Current practice regarding ultrasound scanning to determine access sites is variable; some centres use routine ultrasound scanning but others offer a more selective approach. The recommendation would not involve a large change in practice and is likely to be cost saving because of the reduced need for repeat intervention.

Rationale and impact: when to start treatment Rationale The committee agreed that when to start dialysis is a complex decision that should take into account a number of factors symptoms, patient preference, biochemistry, fluid overload and eGFR. The committee noted that some people prefer to have an agreed starting point eGFR , but may need dialysis before this because symptoms are affecting normal daily activities.

Some people with slowly progressing chronic kidney disease may not recognise and report symptoms that indicate dialysis is needed. Taking all this information together, the committee acknowledged several indications for starting dialysis and agreed that these should be considered on an individual basis. The committee agreed that it is important to establish whether the symptoms for example, fatigue and depression are due to uraemia or not, and to discuss their impact on daily life. The committee agreed to make a research recommendation on this to guide future practice. The recommendations reflect common practice for adults and children, and so are not likely to involve a change of practice for most NHS providers or have a substantial resource impact for the NHS in England.

If providers need to change from an earlier to a later initiation strategy, this is likely to be cost saving due to a reduction in time on dialysis. For more information, see evidence review A: initiating renal replacement therapy. The committee agreed that current practice is for people receiving dialysis or conservative management to have an assessment by a specialist dietitian. NICE's guideline on managing hyperphosphataemia in chronic kidney disease recommends assessment by a specialist renal dietitian for those at risk of hyperphosphataemia, which would include these groups of people.

They also considered it current practice for dietary advice to be given after transplantation, although this advice is not always given by a specialist renal dietitian. The committee noted that there is some variation in how long people have to wait for this assessment, and variation in ongoing management.

The committee agreed that dietary advice is important for people with a transplant, particularly straight after the surgery. This was supported by the evidence. The committee noted the importance of the person giving dietary advice having specialist knowledge of dietary requirements in transplant patients.