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Practice Guidelines

Early identification and management of chronic kidney disease: summary of NICE guidance

BMJ 2008; 337 doi: (Published 29 September 2008) Cite this as: BMJ 2008;337:a1530

NICE Guidance on CKD

Crowe et al have provided a succinct summary of NICE guidance on
early identification and management of CKD. 1 We raise two issues with

1. The recommendations for early detection are sensible, offering
testing for those at risk. The test is an estimate of GFR. Unfortunately,
the mandatory reporting of eGFR means that the test is often available
before the identification of risk. A single laboratory test is then
translated not only into a diagnosis but also a stage of a chronic
disease. This is opportunistic screening.2 The error is compounded by
the fact that the MDRD formula for estimating GFR is only moderately
reliable for quantifying the “true” GFR in patients with unequivocally
reduced kidney function but quite unreliable for defining normal renal
function 3.
2. They also describe the recommended modifications to the current version
of the CKD Staging System. Any modification is to be welcomed 4 Former
attempts have been rejected on the grounds that the present system is at
least simple. 5 Stage 3 is to be subdivided into A and B by GFR 30-44 vs.
45-59ml/min/1.73m2 , and for each stage the presence or of proteinuria
defines a subcategory. If this modification is accepted there will be
twelve categories instead of five and 2 suffixes. Where is the evidence
that patients in each of these twelve stages are qualitatively different
from one another? What is more perplexing is the loyalty to perpetuating
Stages 1 and 2. Stage 1 is currently defined as the presence of renal
disease with a “normal or increased” GFR (>90ml/min/1.73m2). Population
studies of the distribution of eGFR show that the majority of normal
subjects have an eGFR of <90ml/min/1.73m2. 6,7 Moreover, the MDRD
formula cannot reliably predict GFR in the 60-120/ml/min/1.73m2 range. It
would be more logical to define Stage 1 as the presence of renal disease
diagnosed by histology, imaging or abnormalities in the urine, but with
renal function preserved within the normal range (95% CI) for age and
gender. 7 It would have been helpful if NICE, having started to modify
the Staging System, had completed a much needed task.

Christopher G Winearls, Consultant Nephrologist, Oxford Radcliffe
Hospitals NHS Trust
Richard Glassock, Emeritus Professor of Medicine, David Geffen School of
Medicine, UCLA

Competing interests: None

1. Crowe E, Halpin D, Stevens, P- On behalf of the Guideline
Development Group. Guidelines. Early identification of and management of
chronic kidney disease: a summary of NICE guidance. BMJ 2008;337:612-815
2 Glassock R and Winearls C. Screening for CKD with eGFR: doubts and
dangers. Clin J Am Soc Nephrol 2008;3:1563-8.
3. Froissart M, Rossert J, Jacquot C, Paillard M, Houllier. Predictive
performance of the Modification of Diet in Renal Disease and the Cockcroft
-Gault equations for estimating renal function. J Am Soc Nephrol 2005;
4. Bauer C, Melamed ML and Hostetter TH. Staging of Chronic Kidney
Disease: Time for a course correction. J Am Soc Nephrol 2008; 19:844-6
5. Eknoyan G. Chronic kidney disease definition and classification: the
quest for refinements. Kidney Int 2007;72:1183-1185
6 de Lusignan S, Chan T, Stevens P, O'Donoghue D, Hague N, Dzregah B, Van
Vlymen J, Walker M, Hilton S. Identifying patients with chronic kidney
disease from general practice computer
records. Fam Pract. 2005 22:234-41
7. Wetzels JFM, Kiemency LALM, Swinkels DW, Willems HL, den Heijer M. Age
-and gender specific reference values of estimated GFR in Caucasians: The
Nijmegen Biochemical Study. Kidney Int 2007; 72:632-637

Competing interests:
None declared

Competing interests: No competing interests

20 October 2008
Christopher G Winearls
Consultant Nephrologist
Richard Glassock
Oxford Kidney Unit OX3 7LJ