Chronic
kidney disease- Flowchart
- Renal disease management quick view
- Classification
- Identification of chronic kidney disease
- Initial management of reduced eGFR
- Assessment of proteinuria
- Assessment of haematuria
- Management of chronic kidney disease
- Referral of chronic renal disease
- Referral information
- Top tips: CKD
Guide for identification, referral and management of adults with chronic kidney disease
Classification
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GFR=glomerular filtration rate.
*The equation used to estimate GFR depends on which serum creatinine assay is used. For creatinine assays that produce results aligned to isotope dilution mass spectrometric measurements, the equation is: eGFR (ml/min/1.73 m2)=175x[serum creatinine (µmol/l)x0.011312]-1.154x[age]-0.203x[1.210 if black]x[0.742 if female]
Identification of chronic kidney disease
Serum creatinine and eGFR should be measured at initial assessment and then at least annually in adult patients with conditions associated with high risk of silent development of CKD, including:
- Diabetes Mellitus
- Hypertension
- Coronary Heart Disease
- Heart Failure
- Peripheral Vascular Disease
- Stroke Disease
- Bladder Outflow Obstruction
- Surgical Urinary Diversion
- Patients taking ACE-i/ARB or diuretic therapy.
Early detection of chronic kidney disease
Early identification and management of chronic kidney disease: summary of NICE guidance
Initial management of reduced eGFR
The majority of reduced eGFR results will be reported in patients with stable chronic kidney disease. However all patients need assessment: -
- To distinguish between patients with chronic kidney disease and those with potential acute renal failure
- To identify patients with haematuria, proteinuria, severe hypertension, progressive reduction in eGFR or bladder outflow obstruction who may benefit from specialist referral
If there has been a fall in eGFR or increase in creatinine since the last test or there are no previous results follow these steps.
- Measure blood pressure and dipstick test urine for blood and protein
- If severe hypertension (SBP>180), and/or heavy proteinuria (3+ or more) and/or microscopic haematuria (3+ or more), discuss case with local nephrologist urgently (see referral section).
- If normotensive or mild/moderate hypertension (SBP<180), and/or absent or mild proteinuria (2+ or less, and or absent or mild haematuria (2+ or less), manage any symptoms as appropriate and repeat the eGFR within 7 days to exclude acute renal failure.
- If eGFR is further reduced, refer patient to local Renal Unit.
- If eGFR is stable at 7 days, repeat the investigation after 3 months
- Arrange renal ultrasound in any patient with symptoms of bladder outflow obstruction.
If comparison with previous results shows that eGFR / raised creatinine is stable ensure that the following have been performed.
- Dipstick urine test for blood and protein.
- Renal ultrasound in any patient with symptoms of bladder overflow obstruction.
- Control of blood pressure.
Assessment of proteinuria
ACR is albumin:creatinine ratio
- Best used in preference to PCR (protein:creatinine ratio) or dipstick or 24 hour urinalysis as it is more accurate
- Best on an early morning sample but can be done on a random sample
Who do we check ACR on?
- eGFR <60
- diabetes
- hypertension
- CHD
- Structural renal disease
- Renal calculi
- Prostatic hypertrophy
- Multi-system disease with renal involvement e.g. SLE
- Hereditary kidney disease or FH stage 5 CKD
- Microscopic or macroscopic haematuria
What to do next
- If random is 30 to 70mg/mmol, check an early morning sample
- If ACR > 70mg/mmol – refer (unless diabetes)
- In diabetes, an ACR >2.5mg/mmol is significant
- If ACR >30mg/mmol and haematuria, refer
- If ACR 30 – 70mg/mmol, bp is well-controlled and eGFR is stable – monitor
Assessment of haematuria
Dipstick urinalysis for blood should ideally be performed mid-menstrual cycle in women.
- If dipstick positive for blood send MSU to exclude infection. Treat any infection and repeat dipstick test.
- If dipstick remains for blood, refer to NEPHROLOGY if age < 40, and/or heavy proteinuria (2+ or more)
- If dipstick remains positive for blood, refer all other patients to UROLOGY. Patients aged over 50 and those with macroscopic haematuria should be referred using the 2-week rule. If urology investigations are negative refer to nephrology if eGFR <60ml/min/1.73m˛ and/or severe hypertension (SBP>180)
Management of chronic kidney disease
Patients identified as having CKD i.e. eGFR <60ml/min/1.73˛ or eGFR >60ml/min/1.73˛ with another indicator of chronic kidney disease should have a management plan aimed at slowing decline in kidney function and reducing cardiovascular risk, taking into consideration age and co-morbidity. Patients with chronic kidney disease have greatly increased cardiovascular risk.
- Creatinine (eGFR), FBC, bone biochemistry (Ca, PO4 alkaline phosphatase), dipstick urinalysis (and/or ACR if diabetic) annually if renal function is stable, or 3-6 monthly if renal function declining.
- Target blood pressure <130/80 in patients with CKD, or <125/75 if associated heavy proteinuria (urine protein 2+ or more) or diabetes with microalbuminuria or proteinuria.
- Patients with diabetes and microalbuminuria, proteinuria or reduced eGFR should have tight glycaemic control and aggressive cardiovascular risk reduction
- ACE inhibitors are first line treatment for patients with proteinuria or diabetics with microalbuminuria even if reduced eGFR. ARBs are an alternative if cough develops on the ACE inhibitor. Creatinine and potassium should be measured before commencing these drugs and 10-14 days after commencement or subsequent dosage increase and at least annually thereafter (see section ‘REFERRAL OF CHRONIC KIDNEY DISEASE’)
The finding of hyperkalaemia (>6.0mmol/1) should not lead to the immediate discontinuation of ACEI/ARB therapy. Other causes of hyperkalaemia (haemolysis, high dietary potassium intake, concomitant potassium-conserving medication [amiloride, triamterene, spironolactone], or nephrotoxic medication [NSAIDs] should be excluded first.
- Annual lipid profile and lipid management as per JBS2ą guidance with introduction of lipid lowering treatment if appropriate (note dose reduction needed if using fibrates)
- Aspirin if established atheromatous vascular disease and for primary prevention if age >50 diabetes, target organ damage or calculated 10yr CVD risk ¬>20% when blood pressure controlled to <150/90.
- Smoking and weight advice.
- Pneumococcal and influenza immunisation.
- Avoidance of NSAIDs and other potentially nephrotoxic medications if possible.
- ą Joint British Societies Guidelines December 2005
Referral of chronic renal disease
Urgent referral is indicated for:
- Rapidly deteriorating kidney function.
- Newly detected established renal failure (eGFR <15ml/min/1.73m˛)
- Nephrotic syndrome (dipstick proteinuria 3+ or more, oedema)
- Malignant hypertension.
Routine referral is indicated for:
- eGFR falls by >5ml/min/1.73m˛ per year.
- eGFR <30ml/min/1.73˛ if suitable for renal replacement therapy or for potential further reduction of cardiovascular risk
- Fall in eGFR of 20% or rise in creatinine of 30% after introduction or dosage increase of ACE inhibitor (ACE1) or Angiotension Receptor Blocker (ARB)
- CKD with Refractory hypertension (BP>150/90 despite good compliance with 3 drugs)
- CKD with haemoglobin < 10g/dl, when other causes of anaemia excluded
- CKD with persistent abnormal calcium or phosphate
Referral information
Standard referral information plus:
- Serial eGFR/creatinine results
- Dipstick urinalysis result (and urine ACR if diabetic)
- Serial blood pressure measurements
- Renal ultrasound report (if available)