Commentary: Controversies in NICE guidance on chronic kidney disease

doi:10.1136/bmj.a1793

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Martin J Landray, reader in epidemiology and honorary consultant physician1,
Richard J Haynes, clinical research fellow and specialist registrar in nephrology12

¹Clinical Trial Service Unit and Epidemiological Studies Unit, University of Oxford, Oxford OX3 7LF
²Oxford Kidney Unit, Churchill Hospital, Oxford OX3 7LE

Correspondence to: M J Landray martin.landray{at}ctsu.ox.ac.uk

New NICE guidelines seek to improve health outcomes for individuals with chronic kidney disease. They emphasise the role of primary care in dealing with two important questions: how should we assess and reduce the risk of cardiovascular events that are present among all patients with chronic kidney disease; and how can we identify the minority of individuals who are likely to progress to advanced kidney disease (and require specialist nephrological services)?

Definition and staging

One of the most controversial issues in writing such guidelines is the definition of chronic kidney disease, which relies on the ability to estimate glomerular filtration rate (GFR). As the NICE authors recognise, the current, creatinine based formulas are woefully inadequate among the 90-95% of the population who have “normal” or “moderately impaired” kidney function (GFR >45 ml/min/1.73m²).

The staging system based on GFR largely ignores other measures of kidney damage—proteinuria, for example—which are useful indicators of the risk of progression of renal …