CKD

CKD1 – 5

Other evidence of chronic kidney damage

Renal USS if

Identifying progress

ACR

ACEi & ARB

Hypertension targets

Referral

CKD1 [>90 with other evidence of chronic kidney damage*]

  • Monitor 12 monthly U&E

CKD2 [60-89 with other evidence of chronic kidney damage*]

  • Monitor 12 monthly U&E

CKD3a [45-59] [> 70y old, if stable over time, unlikely of clinical significance]

  • Monitor 6 monthly U&E
  • Check ACR

CKD3b [30-44]

  • Monitor 6 monthly U&E
  • Check Hb, ACR

CKD4 [15-29]

  • Monitory 3 monthly U&Es
  • Check Hb, calcium, phosphate and PTH, ACR

CKD5 [<15 or on dialysis]

  • Monitor 6 weekly U&E
  • Check Hb, calcium, phosphate and PTH, ACR

*Other evidence of chronic kidney damage

  • If CKD2 and none of below, do not subject to further investigations
    • Persistent microalbuminuria
    • Persistent proteinuria [morning ACR]
    • Persistent haematuria (after exclusion of other causes, e.g. urological disease)
    • Structural abnormalities on imaging (e.g. PCOS, reflux nephropathy)

Renal USS if

  • Progressive CKD
  • Macroscopic or persistent microscopic haematuria
  • Suspected urinary tract obstruction
  • Fhx of polycystic kidney disease and > 20
  • CKD4 or 5

Identifying progress

  • Newly identified – repeat eGFR within 2/52 [to exclude acute decline]
  • Known cases – obtain minimum of 3 eGFR over 3/12
  • Progression is eGFR decline [>5 in 1y] or [>10 within 5y]

ACR

  • Clinically significant proteinuria when [ACR >= 30]
  • Microalbuminuria
    • Men – ACR > 2.5
    • Women – ACR > 3.5

ACEi & ARB

  • Offer if microalbuminuria or proteinuria
  • Drug of choice in hypertension and CKD
  • Starting and monitoring
    • U&Es 1-2/52 after dose change
    • Do not start if K significantly above normal range
    • Stop ACE/ARB if [k>= 6]
    • Stop or reduce to last dose if [eGFR drop >= 25% or creatine increase >= 30%]
    • If [eGFR drop < 25% or creatine increase < 30%] then recheck U&Es after 1-2/52 to ensure no further decline.

Hypertension targets

  • Target < 130/80 if [CKD and diabetes] or [ACR > 70]
  • Target < 140/90 in others

Referral

  • CKD4 and 5
  • ACR >= 70
  • ACR >= 30 and haematuria
  • eGFR decline [>5 in 1y] or [>10 within 5y]
  • HTN despite 4 anti-hypertensives
  • Suspected renal artery stenosis or rare/genetic cause for CKD