Chronic kidney disease in adults: assessment and management

National Institute for Health and Care Excellence


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Investigations for chronic kidney disease

Who should be tested for CKD

  • Monitor GFR at least annually in people prescribed drugs known to be nephrotoxic, such as calcineurin inhibitors (for example, cyclosporin or tacrolimus), lithium and non-steroidal anti-inflammatory drugs (NSAIDs) 
  • Offer testing for CKD using eGFR creatinine and ACR to people with any of the following risk factors:
    • diabetes
    • hypertension
    • acute kidney injury
    • cardiovascular disease (ischaemic heart disease, chronic heart failure, peripheral vascular disease or cerebral vascular disease)
    • structural renal tract disease, recurrent renal calculi or prostatic hypertrophy
    • multisystem diseases with potential kidney involvement – for example, systemic lupus erythematosus
    • opportunistic detection of haematuria
    • family history of end-stage kidney disease (GFR category G5) or hereditary kidney disease
  • Do not use age, gender or ethnicity as risk markers to test people for CKD. In the absence of metabolic syndrome, diabetes or hypertension, do not use obesity alone as a risk marker to test people for CKD

Classification of chronic kidney disease

  • Classify CKD using a combination of GFR and ACR categories. Be aware that:
    • increased ACR is associated with increased risk of adverse outcomes
    • decreased GFR is associated with increased risk of adverse outcomes
    • increased ACR and decreased GFR in combination multiply the risk of adverse outcomes
  • Do not determine management of CKD solely by age

Table 1 Classification of chronic kidney disease using GFR and ACR categories

Investigating the cause of CKD and determining the risk of adverse outcomes

  • Agree a plan to establish the cause of CKD during an informed discussion with the person with CKD, particularly if the cause may be treatable (for example, urinary tract obstruction, nephrotoxic drugs or glomerular disease)
  • Use the person's GFR and ACR categories to indicate their risk of adverse outcomes (for example, CKD progression, acute kidney injury, all-cause mortality and cardiovascular events) and discuss this with them

Indications for renal ultrasound

  • Offer a renal ultrasound scan to all people with CKD who:
    • have accelerated progression of CKD
    • have visible or persistent invisible haematuria
    • have symptoms of urinary tract obstruction
    • have a family history of polycystic kidney disease and are aged over 20 years
    • have a GFR of less than 30 ml/min/1.73 m2 (GFR category G4 or G5)
    • are considered by a nephrologist to require a renal biopsy
  • Advise people with a family history of inherited kidney disease about the implications of an abnormal result before a renal ultrasound scan is arranged for them

Frequency of monitoring

  • Agree the frequency of monitoring (eGFRcreatinine and ACR) with the person with, or at risk of, CKD; bear in mind that CKD is not progressive in many people
  • See table below to guide the frequency of GFR monitoring for people with, or at risk of, CKD, but tailor it to the person according to:
    • the underlying cause of CKD
    • past patterns of eGFR and ACR (but be aware that CKD progression is often non-linear)
    • comorbidities, especially heart failure
    • changes to their treatment (such as renin–angiotensin–aldosterone system [RAAS] antagonists, NSAIDs and diuretics)
    • intercurrent illness
    • whether they have chosen conservative management of CKD

Table 2 Frequency of monitoring of GFR (number of times per year, by GFR and ACR category) for people with, or at risk of, CKD


Defining progression

  • Define accelerated progression of CKD as:
    • a sustained decrease in GFR of 25% or more and a change in GFR category within 12 months or
    • a sustained decrease in GFR of 15 ml/min/1.73 m2 per year
  • Take the following steps to identify the rate of progression of CKD:
    • obtain a minimum of 3 GFR estimations over a period of not less than 90 days
    • in people with a new finding of reduced GFR, repeat the GFR within 2 weeks to exclude causes of acute deterioration of GFR—for example, acute kidney injury or starting renin–angiotensin system antagonist therapy
  • Be aware that people with CKD are at increased risk of progression to end-stage kidney disease if they have either of the following:
    • a sustained decrease in GFR of 25% or more over 12 months or
    • a sustained decrease in GFR of 15 ml/min/1.73 m2 or more over 12 months
  • When assessing CKD progression, extrapolate the current rate of decline of GFR and take this into account when planning intervention strategies, particularly if it suggests that the person might need renal replacement therapy in their lifetime

Risk factors associated with CKD progression

  • Work with people who have any of the following risk factors for CKD progression to optimise their health:
    • cardiovascular disease
    • proteinuria
    • acute kidney injury
    • hypertension
    • diabetes
    • smoking
    • African, African-Caribbean or Asian family origin
    • chronic use of NSAIDs
    • untreated urinary outflow tract obstruction
  • In people with CKD the chronic use of NSAIDs may be associated with progression and acute use is associated with a reversible decrease in GFR. Exercise caution when treating people with CKD with NSAIDs over prolonged periods of time. Monitor the effects on GFR, particularly in people with a low baseline GFR and/or in the presence of other risks for progression

Acute kidney injury and CKD

  • Monitor people for the development or progression of CKD for at least 2–3 years after acute kidney injury, even if serum creatinine has returned to baseline
  • Advise people who have had acute kidney injury that they are at increased risk of CKD developing or progressing

Information and education

  • Offer people with CKD education and information tailored to the severity and cause of CKD, the associated complications and the risk of progression
  • When developing information or education programmes, involve people with CKD in their development from the outset. The following topics are suggested.
    • what is CKD and how does it affect people?
    • what questions should people ask about their kidneys?
    • what treatments are available for CKD, what are their advantages and disadvantages and what complications or side effects may occur as a result of treatment/medication?
    • what can people do to manage and influence their own condition?
    • in what ways could CKD and its treatment affect people's daily life, social activities, work opportunities and financial situation, including benefits and allowances available?
    • how can people cope with and adjust to CKD and what sources of psychological support are available?
    • when appropriate, offer information about renal replacement therapy (such as the frequency and length of time of dialysis treatment sessions or exchanges and pre-emptive transplantation) and the preparation required (such as having a fistula or peritoneal catheter)
    • conservative management and when it may be considered
  • Offer people with CKD high-quality information or education programmes as appropriate to the severity of their condition to allow time for them to fully understand and make informed choices about their treatment
  • Healthcare professionals providing information and education programmes should ensure they have specialist knowledge about CKD and the necessary skills to facilitate learning
  • Healthcare professionals working with people with CKD should take account of the psychological aspects of coping with the condition and offer access to appropriate support – for example, support groups, counselling or a specialist nurse

Lifestyle advice

  • Encourage people with CKD to take exercise, achieve a healthy weight and stop smoking

Dietary interventions

  • Offer dietary advice about potassium, phosphate, calorie and salt intake appropriate to the severity of CKD
  • Where dietary intervention is agreed this should occur within the context of education, detailed dietary assessment and supervision to ensure malnutrition is prevented

Low-protein diets

  • Do not offer low-protein diets (dietary protein intake less than 0.6–0.8 g/kg/day) to people with CKD

Self-management

  • Ensure that systems are in place to:
    • inform people with CKD of their diagnosis
    • enable people with CKD to share in decision-making about their care
    • support self-management (this includes providing information about blood pressure, smoking cessation, exercise, diet and medicines) and enable people to make informed choices
  • Give people access to their medical data (including diagnosis, comorbidities, test results, treatments and correspondence) through information systems, such as Renal PatientView, to encourage and help them to self-manage their CKD

Referral criteria

  • Take into account the individual's wishes and comorbidities when considering referral
  • People with CKD in the following groups should normally be referred for specialist assessment:
    • GFR less than 30 ml/min/1.73 m2 (GFR category G4 or G5), with or without diabetes
    • ACR 70 mg/mmol or more, unless known to be caused by diabetes and already appropriately treated
    • ACR 30 mg/mmol or more (ACR category A3), together with haematuria
    • sustained decrease in GFR of 25% or more, and a change in GFR category or sustained decrease in GFR of 15 ml/min/1.73 m2 or more within 12 months
    • hypertension that remains poorly controlled despite the use of at least 4 antihypertensive drugs at therapeutic doses (see also Hypertension [NICE clinical guideline 127])
    • known or suspected rare or genetic causes of CKD
    • suspected renal artery stenosis
  • Consider discussing management issues with a specialist by letter, email or telephone in cases where it may not be necessary for the person with CKD to be seen by the specialist
  • Once a referral has been made and a plan jointly agreed (between the person with CKD or their carer and the healthcare professional), it may be possible for routine follow-up to take place at the patient's GP surgery rather than in a specialist clinic. If this is the case, criteria for future referral or re-referral should be specified
  • People with CKD and renal outflow obstruction should normally be referred to urological services, unless urgent medical intervention is required – for example, for the treatment of hyperkalaemia, severe uraemia, acidosis or fluid overload

Pharmacotherapy

Blood pressure control

In people with CKD aim to keep the systolic blood pressure below 140 mmHg (target range 120–139 mmHg) and the diastolic blood pressure below 90 mmHg

In people with CKD and diabetes, and also in people with an ACR of 70 mg/mmol or more, aim to keep the systolic blood pressure below 130 mmHg (target range 120–129 mmHg) and the diastolic blood pressure below 80 mmHg

Choice of antihypertensive agent

  • Offer a low-cost renin–angiotensin system antagonist to people with CKD and:
    • diabetes and an ACR of 3 mg/mmol or more (ACR category A2 or A3)
    • hypertension and an ACR of 30 mg/mmol or more (ACR category A3)
    • an ACR of 70 mg/mmol or more (irrespective of hypertension or cardiovascular disease)
  • Do not offer a combination of renin–angiotensin system antagonists to people with CKD
  • Follow the treatment recommendations in Hypertension(NICE clinical guideline 127) for people with CKD, hypertension and an ACR of less than 30 mg/mmol (ACR categories A1 and A2), if they do not have diabetes
  • To improve concordance, inform people who are prescribed renin–angiotensin system antagonists about the importance of:
    • achieving the optimal tolerated dose of renin–angiotensin system antagonists and
    • monitoring eGFR and serum potassium in achieving this safely
  • In people with CKD, measure serum potassium concentrations and estimate the GFR before starting renin–angiotensin system antagonists. Repeat these measurements between 1 and 2 weeks after starting renin–angiotensin system antagonists and after each dose increase
  • Do not routinely offer a renin–angiotensin system antagonist to people with CKD if their pretreatment serum potassium concentration is greater than 5.0 mmol/litre
  • When hyperkalaemia precludes use of renin–angiotensin system antagonists, assessment, investigation and treatment of other factors known to promote hyperkalaemia should be undertaken and the serum potassium concentration rechecked
  • Concurrent prescription of drugs known to promote hyperkalaemia is not a contraindication to the use of renin–angiotensin system antagonists, but be aware that more frequent monitoring of serum potassium concentration may be required
  • Stop renin–angiotensin system antagonists if the serum potassium concentration increases to 6.0 mmol/litre or more and other drugs known to promote hyperkalaemia have been discontinued
  • Following the introduction or dose increase of renin–angiotensin system antagonists, do not modify the dose if either the GFR decrease from pretreatment baseline is less than 25% or the serum creatinine increase from baseline is less than 30%
  • If there is a decrease in eGFR or increase in serum creatinine after starting or increasing the dose of renin–angiotensin system antagonists, but it is less than 25% (eGFR) or 30% (serum creatinine) of baseline, repeat the test in 1–2 weeks. Do not modify the renin–angiotensin system antagonist dose if the change in eGFR is less than 25% or the change in serum creatinine is less than 30%
  • If the eGFR change is 25% or more, or the change in serum creatinine is 30% or more:
    • investigate other causes of a deterioration in renal function, such as volume depletion or concurrent medication (for example, NSAIDs)
    • if no other cause for the deterioration in renal function is found, stop the renin–angiotensin system antagonist or reduce the dose to a previously tolerated lower dose, and add an alternative antihypertensive medication if required

Statins

  • Follow the recommendations in Lipid modification (NICE clinical guideline 181) for the use of statins in CKD

Oral antiplatelets and anticoagulants

  • Offer antiplatelet drugs to people with CKD for the secondary prevention of cardiovascular disease, but be aware of the increased risk of bleeding
  • Consider apixaban in preference to warfarin in people with a confirmed eGFR of 30–50 ml/min/1.73 m2 and non-valvular atrial fibrillation who have 1 or more of the following risk factors:
    • prior stroke or transient ischaemic attack
    • age 75 years or older
    • hypertension
    • diabetes mellitus
    • symptomatic heart failure

References

full guideline available from...
National Institute for Health and Care Excellence, Level 1A, City Tower, Piccadilly Plaza, Manchester, M1 4BT

www.nice.org.uk/guidance/CG182

National Institute for Health and Care Excellence. Chronic kidney disease in adults: assessment and management. July 2014


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