Chronic Kidney Disease – NICE Guidance on a Page

Diagnosis

CKD defined: eGFR < 60 on two consecutive occasions separated by 90 days
Use GFR and ACR to indicate risk of adverse outcome
Classification eGFR > 90 = 5; 60-89 = 4; 45-59 = 3a; 30-44 = 3b; 15-134 = 5; < 15 = 5
ACR < 3 = normal (A1); 3-30 = moderately increased (A2); > 30 = severely increased (A3)
Note eGFRcreatinine, eGFRcystatinC demark the basis of estimation, if accurate measurement required: inulin, 51Cr-EDTA
Accelerated Progression: sustained decrease of > 25% GFR and change in category within 12 mths OR a sustained decrease in GFR of 15 per year, more likely to reach end stage
Extrapolate rate of decline and account in planning intervention strategies
Risk factors for progression: Diabetes; CVD; Proteinuria; AKI; HTN; Smoking; African; Chronic NSAIDs; untreated urinary outflow obstruction

If creatinine measured, eGFR should be reported per CKD-EPI algorithm, if African x 1.159, interpret with caution if have extreme muscle mass
Frequency: agree with patient, not progressive in many, tailor according to underlying cause, function of stage of kidney disease
Test Creatinine annually if nephrotoxic drugs: NSIADs, Lithium, Calcineurin Inhibitors (Tacrolimus), noted chronic NSAID associated with progression, acute with reversible change
Test ACR & eGFRcreatinine: Diabetes; AKI; CVD; structural kidney disease; Fx end stage renal failure
Renal ultrasound: if accelerated progression of CKD; GFR < 30; persistent invisible haematuria; symptoms of urinary tract obstruction; Fx of PKD

Use urine ACR in preference to protein : creatinine ratio (PCR)
Do not use strips unless able to express at low concentration as ACR
Proteinuria if ACR > 3 mg/mmol, if initial result 3-70, retest with early morning sample
Quantify urine albumin loss if diabetic or eGFR < 60

Use reagent strips and investigate for urinary tract malignancy if result of 1+ or more, with positives in 2 out of 3 tests, followed up annually

Lifestyle: encourage people with CKD to take exercise, achieve a healthy weight and stop smoking
Diet: offer dietary advice re potassium, phosphate, calorie and salt intake appropriate to severity
Specialist referral: GFR < 30; ACR > 70 or > 30 with haematuria, or accelerated progression

CKD aim BP < 140/90, or if diabetes < 130/80
ACE inhibitor: diabetes and ACR > 3 (A2), hypertension and ACR > 30 (A3) OR ACR > 70
Expect GFR to fall, continue if GFR change < 25% or creatinine rise < 30%
Measure K+ before starting ACE (potassium sparing), do not offer if > 5.0, investigate accordingly
HTN: All others follow CG127
Statins: follow CG181
Anti-platelet: offer for secondary prevention of CVD
Consider Apixiban in preference to Warfarin if GFR 30-50 and AF with prior stroke, HTN, DM, >75

Do not routinely measure Ca2+, PO4-, PTH, Vitamin D levels if GFR > 30
Vitamin D deficiency + CKD: Colecalciferol or Ergocalciferol, but not vitamin D supplements
Anaemia: check Hb is GFR < 45