Chronic kidney disease (Guidelines)

TAM (Treatments and Medicines) NHS Highland
NHS Highland

Audience

  • Argyll & Bute HSCP and/or Highland HSCP
  • Primary and/or Secondary Care.

Screening and diagnosis CKD

Patients at risk:

  • Diabetes
  • Hypertension
  • Acute kidney injury (minor patients for CKD for at least 3 years after Acute Kidney Injury (AKI), even if serum creatinine returned to baseline)
  • Cardiovascular disease
  • Structural renal tract disease, recurrent renal calculi, prostatic hypertrophy
  • Multisystem disease with potential kidney involvement - e.g. Systemic lupus erythematosus (SLE)
  • Family history of End stage renal disease (ESRD) (GFR category CKD5) or hereditary kidney disease
  • Opportunistic detection of haematuria
  • Nephrotoxic drugs: lithium, NSAIDs, ACEI, ARBs, ciclosporin, tacrolimus

Proteinuria

  • Do not use reagent sticks to diagnose proteinuria
  • Urine albumin: creatinine ratio (ACR) is more sensitive than urine protein: creatinine ratio (UPCR) at low levels of proteinuria
  • ACR will be used for screening. A normal result is ACR <3 mg/mmol
  • Proteinuria is not an indication for urine culture in the absence of symptoms of urinary tract infection (UTI)
  • In patients with symptomatic UTI, the test for proteinuria should be delayed until after UTI resolved
  • If urine ACR >70 mg/mmol, a protein: creatinine ratio will be checked

Testing for haematuria

  • When testing for haematuria use reagent strips rather than urine microscopy.
  • Presence of haematuria in 2 out of 3 reagent strip tests confirms persistent invisible haematuria.
  • Persistent invisible haematuria with or without proteinuria should prompt investigation for urological malignancy in those aged over 50.
  • Persistent invisible haematuria with proteinuria should be followed up annually with repeat testing for haematuria, ACR, GFR and BP as long as haematuria persists.

Associated guidance:

Management of chronic kidney disease (CKD) irrespective of stage

Blood pressure control

  • Aim to keep SBP <140 mmHg (target 120 to 139) and DBP <90 mmHg
  • In people with CKD and diabetes, and also in people with ACR >70 mg/mmol, aim to keep SBP <130 mmHg (target 120 to 129) and DBP <80mmHG
  • Use ACEI or ARB as first choice in people with CKD and diabetes and ACR >3mg/mmoL, hypertension and ACR >30mg/mmoL, ACR >70mg/mmoL irrespective of hypertension
  • DO NOT offer a combination ACEI and ARB to people with CKD
  • Check U&Es before starting ACEI or ARB and 1 to 2 weeks after each dose adjustment
  • Do not routinely offer ACEI or ARB when potassium >5.0 (NICE)
  • Stop ACEI or ARB if potassium >6.0mmol/L
  • Give advice on smoking cessation, weight reduction, exercise, alcohol intake and sodium restriction
  • Promote self-management: Encourage home BP readings (target <135/85 and <125/75 if ACR >70)
  • Frail elderly: consider more relaxed target

Lipid management

Medication Review

  • Avoid NSAIDs
  • Avoid trimethoprim if GFR <30
  • Avoid nitrofurantoin if GFR <60
  • Review all drugs. Ensure correct doses
  • Use oxynorm as opiate in patients with GFR <30

SGLT-2 inhibitors

Dapagliflozin is in the Highland Formulary. Use as per SMC dapagliflozin (Forxiga) (scottishmedicines.org.uk):

  • Indication: Adults for the treatment of Chronic Kidney Disease
  • SMC restriction:
    • in patients with an estimated glomerular filtration rate >25 to <75 ml/min at treatment initiation
    • are receiving an ACE inhibitor or ARB (unless they are not tolerated or contraindicated) and
    • have a urine albumin: creatinine ratio of at least 23 mg/mmol or type 2 diabetes or both

Renal Complications

  • Measure serum calcium, phosphate and PTH in people with GFR <30 mL/min
  • Check haemoglobin in people with GFR <45mL/min
  • Consider oral bicarbonate supplementation in patients with GFR <30 mL/min and bicarbonate <20 mmol/L

GFR

GFR Category

ACR Category (mg/mmol)

A1: <3
Normal to mildly increased

A2: 3 to 30
 Moderately increased

A3: >30
Severely increased

G1: >90

Normal and high

 No CKD in the absence of markers of kidney damage

Manage in primary care according to recommendations

Refer to renal unit if the person has

  • A sustained decrease in GFR of 25% or more and a change in GFR category or sustained decrease in GFR of 15 ml/min or more within 12 months
  • Hypertension that remains poorly controlled despite the use of at least 4 antihypertensive drugs
  • Known or suspected rare or genetic causes of CKD
  • Suspected underlying systemic disease
  • Suspected renal artery stenosis
  • ACR >70 mg/mmol or more unless known to be caused by diabetes and already appropriately treated
  • ACR >30 mg/mmol and haematuria

Manage in primary care according to recommendations

Refer to renal unit if the person has any of the criteria in A2, or: 

  • ACR 70mg/mmol or more, unless known to be caused by diabetes and already appropriately treated
  • Haematuria

G2: 60 to 89

Mild reduction related to normal range for a young adult

G3a:
45 to 59

Mild to moderate reduction

G3b:
30 to 44

Moderate to severe reduction

G4: 15 to 29

Severe reduction

 Refer for specialist assessment

G5: <15

Kidney failure

Frequency for monitoring of GFR

Number of times per year, by GFR and ACR category for people with or at risk of CKD

GFR Category

ACR Categories (mg/mmol)

A1: <3 Normal to mildly increased

ACR Categories (mg/mmol)

A2 3 to 30 Moderately increased

ACR Categories (mg/mmol)

A3 >30 Severely increased

G1 >90
Normal and High

≤ 1

1

≥ 1

G2 60 to 89
Mild reduction related to normal range for young adult

≤ 1

1

≥ 1

G3a 45 to 59
Mild to Moderate reduction

1

1

2

G3b 30 to 44
Moderate to Severe reduction

≤2

2

≥2

G4 15 to 29
Severe reduction

2

2

3

G5 <15
Kidney failure

4

≥ 4

≥ 4

This should be tailored according to:

  • The underlying cause of CKD
  • Past patterns of eGFR and ACR (but be aware CKD progression is often non linear)
  • Co-morbidities, especially heart failure
  • Changes to treatment (such as ACEI/ARBs, NSAIDs, diuretics)

Abbreviations

Abbreviation  Meaning 
ACEI  Angiotensin converting enzyme inhibitors
ACR  Urine albumin to creatinine ratio
AKI Acute kidney injury
ARB  Angiotensin II receptor blockers
CKD Chronic kidney disease
DBP  Diastolic blood pressure
eGFR Estimated glomerular filtration rate
NSAIDs Nonsteroidal anti-inflammatory drugs 
SBP  Systolic blood pressure
U&Es  Urea and electrolytes

Editorial Information

Last reviewed: 22/11/2023

Next review date: 30/11/2026

Author(s): Renal Department .

Version: 3

Approved By: TAMSG of ATDC

Reviewer name(s): Dr N Joss, Consultant Nephrologist.

Document Id: TAM361

Related resources

Further information for Health Care Professionals

  • eg SIGN
  • eg NICE
References

Further information for Patients