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Audit Protocol – Chronic Kidney Disease
For renally eliminated medication, dose adjustments are necessary to prevent the
adverse effects associated with potentially elevated drug concentrations. In addition,
some medications can worsen renal function and should therefore be avoided or
carefully considered for use in patients with renal impairment. Studies that have
evaluated medication-related hospital admissions showed that impaired renal
function is a potential risk factor for these admissions1, 2.
General Practices are required to keep a register of patients with impaired renal
function as part of their Quality Outcomes Framework (QOF). The patient
management requirements of QOF are summarised in the appendix. The stages for
chronic kidney disease (CKD) are summarised below:
Stage 3
eGFR* is 30 – 59mL/min
Stage 4
eGFR* is 15 – 29mL/min
Stage 5
eGFR* is below 15mL/min or on dialysis
This audit focuses on reviewing the medicines of patients who are categorised as
being in CKD stages 4 and 5.
Patients with CKD stages 4 & 5 should be searched using search criteria as eGFR ≤
30mL/min. NB: Do not conduct the search as clinical codes CKD stages 4 and 5
because this may not pick up all patients if they have not been correctly coded by
the Practice. Do not include patients with eGFR <30 on only 1 occasion (ie. whose
eGFR has subsequently recovered after an episode of acute kidney injury).
Having identified patients with CKD 4 or 5:
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Review the medicines of all patients who are categorised as being in CKD
stages 4 and 5
Compile a list of all patients who need their dose modifying using the Renal
Drug Handbook as a reference source. Send a task message (Patient Note) to
the patient’s usual GP with any recommended dose changes or attempt to
contact them directly for any issues which are judged as requiring immediate
attention
Confirm that all patients with an eGFR* of less than 15mL/min are under
specialist care. NICE recommends that all patients with CKD 4 and 5 should
be referred for specialist assessment.
Check correspondence from CKD specialists to see if the patient is currently
prescribed an erythropoiesis-stimulating agent (ESA). If so, and if this is not listed
on the patient’s repeat medication at the Practice, recommend that it is added to
the list as a ‘do not issue’ (supplied by hospital) medication, for information.
Arrange with individual Practices any Read-Coding to be undertaken pertaining to
the CKD register
Report any interventions on the HARMS template
Notes
 Where eGFR* has persistently been recorded below 60 the CKD (stage 3) label
continues to apply, even if future management may lead to an improvement in
eGFR.
 The presence of proteinuria is a key risk multiplier at all stages of CKD. The gold
standard test for measuring proteinuria is a 24-hour urine collection; though
problems with timing and completeness make this an impractical test to use in
* All GFR values are normalised to an average surface area (size) of 1.73m²
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general practice. The alternatives are to test the ACR (albumin:creatinine ratio) or
PCR (protein:creatinine ratio) in the urine. ACR is the preferred measure of
proteinuria as it has greater sensitivity than PCR for low levels of proteinuria.
ACE-I and ARBs are generally more effective than other anti-hypertensives in
minimising deterioration in kidney function and this effect is most marked where
there is significant proteinuria.
NICE recommends that if serum potassium rises to ≥ 6.0 mmol/l and other drugs
that promote hyperkalaemia have been discontinued, ACE inhibitors/ARBs should be
stopped.
NICE also recommends that when vitamin D supplementation is indicated in people
with CKD 4 or 5 offer 1-alpha-hydroxycholecalciferol (alfacalcidol) or 1,25dihydroxycholecalciferol (calcitriol) and monitor serum calcium and phosphate
concentrations.
People with stage 3B, 4 and 5 CKD should have their haemoglobin checked to
identify anaemia (Hb < 110 g/L (11.0 g/dL)). NICE CG 114 recommends that
treatment with erythropoiesis-stimulating agents (ESAs) should be offered to people
with anaemia of CKD who are likely to benefit in terms of quality of life and physical
function. The correction to normal levels of Hb with ESAs is not usually
recommended: typically maintain the aspirational Hb range between 110 and 120
g/L for adults. People receiving ESA maintenance therapy should be given iron
supplements to keep their:
serum ferritin levels between 200 and 500 μg/L in both haemodialysis and
non-haemodialysis patients, and either
transferrin saturation level above 20% (unless ferritin is greater than 800
μg/L) or
percentage hypochromic red cells (%HRC) less than 6% (unless ferritin is
greater than 800 μg/L).
(in practice it is likely this will require intravenous iron)
Consult the NICE Pathway for recommendations concerning the use of phosphate
binders in the management of hyperphosphataemia (see reference 4 for link)
Useful References
1. Leendertse AJ, Egberts AC, Stoker LJ, et al.; HARM Study Group. Frequency of and risk factors for
preventable medication-related hospital admissions in the Netherlands. Arch Intern Med
2008;168:1890-6.
2. McDonnell PJ, Jacobs MR. Hospital admissions resulting from preventable adverse drug reactions.
Ann Pharmacother 2002;36:1331-6.
3. The Renal Drug Handbook, third ed. Ed C Ashley & A Currie. Radcliffe Publishing 2009. ISBN-13:978
184619 2
4. NICE Clinical Guideline 73 - Chronic kidney disease. Quick reference guide, Sept 2008, accessed on
11 June 2013 via: http://www.nice.org.uk/nicemedia/live/12069/42119/42119.pdf
5. NICE Clinical Guideline 114 – Anaemia management in people with chronic kidney disease. Quick
reference guide, Feb 2011, accessed on 11 June 2013 via:
http://www.nice.org.uk/nicemedia/live/13329/52857/52857.pdf
6. NICE Pathway – Hyperphosphataemia in people with chronic kidney disease overview. Accessed on
11 June 2013 via:
http://pathways.nice.org.uk/pathways/hyperphosphataemia-in-chronic-kidneydisease#content=view-node%3Anodes-second-line-phosphate-binder-treatment-for-adults
* All GFR values are normalised to an average surface area (size) of 1.73m²
Appendix
Chronic kidney disease (CKD)Points Pt
Quality and Outcomes framework guidance for GMS contract 2013/2014
Indicator
Points Achievement
thresholds
Records
CKD001. The practice can produce a register of patients 6
aged 18 years or over with CKD
(US National Kidney Foundation: Stage 3 to 5 CKD)
Ongoing management
CKD002. The percentage of patients on the CKD register 11
41–81%
in whom the last blood pressure reading, measured in
the preceding 12 months, is 140/85 or less
CKD003. The percentage of patients on the CKD register 9
45–80%
with hypertension and proteinuria who are treated with
an angiotensin converting enzyme inhibitor (ACE-I) or
angiotensin receptor blocker (ARB)
CKD004. The percentage of patients on the CKD register 6
45–80%
whose notes have a record of a urine albumin:creatinine
ratio (or protein:creatinine ratio) test in the preceding 12
months
* All GFR values are normalised to an average surface area (size) of 1.73m²