Download CHRONIC KIDNEY DISEASE

QUICK REFERENCE FOR HEALTHCARE PROVIDERS
MANAGEMENT OF
CHRONIC
KIDNEY DISEASE
IN ADULTS
QUICK REFERENCE FOR HEALTHCARE PROVIDERS
MANAGEMENT OF CHRONIC KIDNEY DISEASE IN ADULTS
KEY MESSAGES
4ARGETED SCREENING IN HIGH RISK GROUPS AND EARLY INTERVENTION IS
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1
QUICK REFERENCE FOR HEALTHCARE PROVIDERS
MANAGEMENT OF CHRONIC KIDNEY DISEASE IN ADULTS
QUICK REFERENCE FOR HEALTHCARE PROVIDERS
MANAGEMENT OF CHRONIC KIDNEY DISEASE IN ADULTS
SCREENING CRITERIA
ALGORITHM 3:
Screen:
TREATMENT FOR CHRONIC KIDNEY DISEASE
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Consider screening patients with:
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Diabetic
Kidney Disease
Non-Diabetic
Kidney Disease
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METHODS OF SCREENING
• Optimise glycaemic
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control
Hypertension
• Strict
BP control
(a) Proteinuria
(BP >140/90
Yes
No
• ACEi/ARB
mmHg)
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Proteinuria
Proteinuria
(>0.5 g/day)
(>1.0 g/day)
(b) Haematuria No
Yes
Yes
No
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General measures in the management of CKD
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• Clinical tip 1: Check potassium and renal function after starting and increasing
sCrdoses
=Serum
Creatinine
of ACEi
and/or ARB. CrCl = Creatinine Clearance
2
6
QUICK REFERENCE FOR HEALTHCARE PROVIDERS
MANAGEMENT OF CHRONIC KIDNEY DISEASE IN ADULTS
ALGORITHM 1:
SCREENING AND INVESTIGATIONS FOR CKD IN PATIENTS WITH DIABETES
3
QUICK REFERENCE FOR HEALTHCARE PROVIDERS
MANAGEMENT OF CHRONIC KIDNEY DISEASE IN ADULTS
FACTORS AFFECTING URINARY PROTEIN EXCRETION
Increases protein excretion
•
•
•
•
•
•
•
•
•
Decreases protein excretion
Strenuous exercise
Poorly controlled DM
Heart failure
UTI
Acute febrile illness
Uncontrolled hypertension
Haematuria
Menstruation
Pregnancy
• ACEi/ARB
• NSAIDs
DIAGNOSIS OF ABNORMAL PROTEIN OR ALBUMIN EXCRETION
Class
Urine
dipstick
reading
Urine
PCR* in
mg/mmol
Urine total
protein
excretion in
g/24 hour
Normal
Negative
<15
<0.15
Negative
<15
<0.15
Trace
15 - 44
0.15 - 0.44
1+
45 - 149
0.45 - 1.49
2+
150 - 449
1.50 - 4.49
3+
450
4.50
“Trace” protein
(Microalbuminuria)
Overt proteinuria
(Macroalbuminuria)
Urine
ACR in
mg/mmol
Urine
albumin
excretion in
mcg/min
(mg/24 hour)
<2.5
(male)
<3.5
(female)
<20
(<30)
2.5 to 30
(male)
3.5 to 30
(female)
20 - 200
(30 - 300)
>30
>200
(>300)
* PCR = Protein: Creatiaine Ratio
INDICATIONS FOR RENAL ULTRASOUND
• A rapid deterioration of renal function (eGFR >5 ml/min/1.73m2 within one year or
10 ml/min/1.73m2 within five years)
• Visible or persistent non-visible haematuria
• Symptoms or history of urinary tract obstruction
• A family history of polycystic kidney disease and age over 20 years
• Stage 4 or 5 CKD
• When a renal biopsy is required
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QUICK REFERENCE FOR HEALTHCARE PROVIDERS
MANAGEMENT OF CHRONIC KIDNEY DISEASE IN ADULTS
ALGORITHM 2:
SCREENING AND INVESTIGATIONS FOR CKD IN PATIENTS WITHOUT DIABETES
Patients with risk factors for CKD
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STAGING OF CHRONIC KIDNEY DISEASE (NKF-KDOQI* STAGING)
Stages of CKD
Stage
GFR (ml/min/1.73m2)
•
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* NKF-KDOQI = National Kidney Foundation: Kidney Disease Outcomes Quality Initiative
QUICK REFERENCE FOR HEALTHCARE PROVIDERS
MANAGEMENT OF CHRONIC KIDNEY DISEASE IN ADULTS
ALGORITHM 3:
TREATMENT FOR CHRONIC KIDNEY DISEASE
Diagnosis of CKD
Diabetic Kidney Disease
Non-Diabetic Kidney Disease
• Optimise glycaemic
control
• Strict BP control
• ACEi/ARB
No
Hypertension
(BP >140/90
mmHg)
Yes
Proteinuria
(>0.5 g/day)
Any antihpertensive to
achieve target BP
Yes
Yes
No
Proteinuria
(>1.0 g/day)
No
• ACEi/ARB preferred
• Non-dihydropyridine
Calcium Channel Blocker
General measures in the management of CKD
• Clinical tip 1: Check potassium and renal function after starting and increasing
doses of ACEi and/or ARB.
6
QUICK REFERENCE FOR HEALTHCARE PROVIDERS
MANAGEMENT OF CHRONIC KIDNEY DISEASE IN ADULTS
GENERAL MEASURES IN THE MANAGEMENT OF CKD
•
•
•
•
•
•
Encourage exercise, weight reduction and smoking cessation.
Restrict sodium intake to <2,400 mg/day (1 teaspoon salt/day).
Avoid excessive protein intake.
Identify other end-organ damage of diabetes and hypertension.
Manage cardiovascular risks including dyslipidaemia.
Monitor renal profile according to individual patient’s characteristics (baseline
renal function, risk factors for CKD progression and specific treatment given).
• Review need to discontinue or reduce doses of medications with worsening renal
function.
• Avoid potentially nephrotoxic agents such as contrast agents, NSAIDs and
traditional medication.
TREATMENT TARGETS FOR PEOPLE WITH CKD
Parameters
Target
Blood pressure
<140/90 (systolic BP range 120 - 139) mmHg
OR
<130/80 (systolic BP range 120 - 129) mmHg in
• patients with proteinuria ≥1 g/day
• patients with DKD
Glycaemic control
HbA1C ≤7.0%, individualised according to co-morbidities
REFERRAL
• A patient with CKD and any of the following criteria should be referred to a
nephrologist/physician:
o heavy proteinuria (urine protein ≥1 g/day or urine PCR ≥0.1 g/mmol)
o haematuria with proteinuria (urine protein ≥0.5 g/day or urine PCR ≥0.05 g/mmol)
o rapidly declining renal function (loss of GFR >5 ml/min/1.73m2 in one year )
o resistant hypertension (failure to achieve target BP despite three
antihypertensive agents including a diuretic)
o suspected renal artery stenosis
o suspected glomerular disease
o suspected genetic causes of CKD
o pregnant or when pregnancy is planned
o eGFR <30 ml/min or serum creatinine >200 µmol/L
o unclear cause of CKD
• Clinical tip 2: When referring to a nephrologist, ensure patient has a recent renal
ultrasound, current blood chemistry and proteinuria quantified.