Abstract
BackgroundNICE Guideline NG107, “Renal replacement therapy and conservative management” (Renal replacement therapy and conservative management (NG107); 2018:1–33) was published in October 2018 and replaced the existing NICE guideline CG125, “Chronic Kidney Disease (Stage 5): peritoneal dialysis” (Chronic kidney disease (stage 5): peritoneal dialysis | Guidance | NICE; 2011) and NICE Technology Appraisal TA48, “Guidance on home compared with hospital haemodialysis for patients with end-stage renal failure”(Guidance on home compared with hospital haemodialysis for patients with end-stage renal failure (Technology appraisal guideline TA48); 2002) The aim of the NICE guideline (NG107) was to provide guidance on renal replacement therapy (RRT), including dialysis, transplant and conservative care, for adults and children with CKD Stages 4 and 5. The guideline is extremely welcomed by the Renal Association and it offers huge value to patients, clinicians, commissioners and key stakeholders. It overlaps and enhances current guidance published by the Renal Association including “Haemodialysis” (Clinical practice guideline: Haemodialysis; 2019) which was updated in 2019 after the publication of the NICE guideline, “Peritoneal Dialysis in Adults and Children” (Clinical practice guideline: peritoneal Dialysis in adults and children; 2017) and “Planning, Initiation & withdrawal of Renal Replacement Therapy” (Clinical practice guideline: planning, initiation and withdrawal of renal replacement therapy; 2014) (at present there are no plans to update this guideline).There are several strengths to NICE guideline NG107 and we agree with and support the vast majority of recommendation statements in the guideline. This summary from the Renal Association discusses some of the key highlights, controversies, gaps in knowledge and challenges in implementation. Where there is disagreement with a NICE guideline statement, we have highlighted this and a new suggested statement has been written.
Highlights
Summary of recommendations Indications for starting dialysis1.1 Indications for starting dialysis1.1.1 Follow the recommendations on referral criteria in National Institute for Health and Care Excellence (NICE)’s guideline on chronic kidney disease in adults 1.1.2 Consider starting dialysis when indicated by the impact of symptoms of uraemia on daily living, or biochemical measures or uncontrollable fluid overload, or at an estimated glomerular filtration rate
We suggest that assisted Peritoneal dialysis (PD) be made available as a viable option, for those who cannot undergo self-care PD. 1.3.10 Consider peritoneal dialysis as the first choice for children 2 years or under 1.3.11 (NICE) Consider HDF rather than Home haemodialysis (HD) in centre Consider HDF or HD at home, taking into account the suitability of the space and facilities 1.3.11 (RA) We recommend that either high flux HD or HDF can be offered as an renal replacement therapy (RRT) modality both in-centre or at home, taking into account the local infrastructure and technology available
1.4.1 Discuss with the person, their family members and carers the risk and benefits of the different types of dialysis access, for example, fistula, graft, central venous or peritoneal dialysis catheter 1.4.2 (NICE) When peritoneal dialysis is planned via a catheter placed by an open surgical technique, aim to create the access around 2 weeks before the anticipated start of dialysis. 1.4.2 (RA) We recommend a break in period of at least 2 weeks after PD catheter insertion, taking into consideration patient preference and local clinical pathways to avoid the need for temporary HD
Summary
1.1.1 Follow the recommendations on referral criteria in NICE’s guideline on chronic kidney disease in adults 1.1.2 Consider starting dialysis when indicated by the impact of symptoms of uraemia on daily living, or biochemical measures or uncontrollable fluid overload, or at an estimated glomerular filtration rate (eGFR of around 5 to 7 ml/min/1.732 if there are no symptoms. 1.1.3 Ensure the decision to start dialysis is made jointly by the person (or, where appropriate, their family members or carers) and their healthcare team. 1.1.4 Before starting dialysis in response to symptoms, be aware that symptoms may be caused by non-renal conditions. Symptoms and eGFR should be taken into account but with some caution if waiting to start until someone is very symptomatic as this could impact on patient wellbeing, education and training for self-care or shared care. Systems and tools such as patient-reported outcome measures (PROMs) could be used to collect and monitor the severity of symptoms reported by patients for an optimal start of RRT. In infants and children there are no data to support starting dialysis on the basis of eGFR alone [1]. Using eGFR to decide when to initiate dialysis is challenging in infants and children under 2 years of age, where rapid growth and ongoing renal maturation make it difficult to estimate GFR
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