How: Example: A laboratory result comes back on one of your patients, an 80-year-old woman, showing that creatinine is 125 μmol/l, which doesn’t seem too bad, but eGFR is calculated as 38 ml/min, CKD stage 3.

Proceed as follows:

  1. Remember that CKD stage 3 affects 3–4% of the population and 30% of people over 70 years, most of whom do not need referral to renal services.
  2. Do not tell the woman and her family that she has CKD: say that her kidney function is slightly reduced, as it is in one-third of older patients.
  3. Check if creatinine has been measured before: if so, is it stable? If not, repeat in near future.
  4. History — previous kidney problems: urinary tract infection, haematuria, stones, protein in urine (pregnancies, medicals), episodes of swelling, and family.
  5. History — cardiovascular risk factors.
  6. Examination — is the bladder palpable (especially elderly men)? If it is — organise urgent ultrasound of urinary tract and discuss with urological services.
  7. Examination — check blood pressure.

What next and when: CKD stage defined by eGFR

CKD stages 1 and 2

  1. Few patients with CKD 1 or 2 require referral to renal services.
  2. Urine — stick test for blood and protein; quantitate proteinuria with albumin creatinine ratio (ACR). Refer to renal services if no blood and ACR >65 mg/mmol or blood and ACR >30 mg/mmol.
  3. In general practice — annual monitoring of creatinine, potassium, cholesterol, and ACR.
  4. Blood pressure control — ‘130/80 mmHg maximum, or 125/75 mmHg in patients with urinary ACR >65 mg/mmol (approximately equivalent to ≥2 on dipstick test)’ is the ideal … but common sense must prevail. Quote from: http://www.renal.org/eGFR/eguide.html  (also cited below)

CKD stage 3

  1. Not all patients with CKD3 require referral to renal services.
  2. Urine — stick test for blood and protein; quantitate proteinuria with protein or albumin creatinine ratio (P/ACR). Refer to renal services if no blood and PCR >100 mg/mmol/ACR >65 mg/mmol or blood and PCR >45 mg/mmol/ACR >30mg/mmol.
  3. Other blood tests: calcium, phosphate, haemoglobin, and cholesterol.
  4. Action — stop poisons (NSAIDs).
  5. Blood pressure control — as above.
  6. Monitoring — check creatinine and (1) and (2) every 6–12 months and consider referral to renal services if reaches CKD stage 4
  7. May need treatment with phosphate binders, vitamin D analogues, iron, epo — discuss with renal services.
  8. Immunisation — influenza and pneumococcal.

CKD stages 4 and 5

As for stage 3, except (in contrast to Stage 3) please refer to or discuss with renal services, except in patients in whom:

  1. All appropriate investigations have been performed and there is an agreed and understood care pathway.
  2. Severe renal impairment is part of another terminal illness.
  3. Further investigation and management is clearly inappropriate.

Patient information

Patient UK Chronic Kidney Disease — A Summary http://www.patient.co.uk/showdoc/27001285/

Patient leaflet on CKD from RCGP http://www.renal.org/eGFR/resources/PatientCKDinfJan2007.pdf

Web links/references

The short CKD eGuide http://www.renal.org/eGFR/eguide.html

The Infirmary of Edinburgh Renal Unit — really helpful GP guide http://renux.dmed.ed.ac.uk/EdREN/Unitbits/GPinfo.html

Source: BJGP top tips 2007