Download RCHT suggested management of Chronic Kidney Disease

Review :
Jan 2012
RCHT suggested management of Chronic Kidney Disease
Management
CKD 1
eGFR > 90
Must have
other
evidence
of kidney
disease **
eGFR 60-89
CKD 2
Mild renal
failure
CKD 3a
eGFR 30-59
45 – 59
Moderate
renal failure
CKD 3b
30 – 44
eGFR 15-29
CKD 4
Severe
renal failure
CKD 5
eGFR <15
End stage
renal failure
U & E’s at least 12 monthly
ACR for all patients at baseline. Yearly only if at risk.
Ca, PO4, ALP, Alb, Cholesterol and Hb initially only
General health advice ‡
Review medication
Treat hyperlipidaemia according to guidelines
ACE-I / A2RB if ACR > 70mg/mmol (>2.5/ 3.5 diabetics)
or other indication
Aspirin if indicated (BP < 140/90mmHg)
Treat BP according to BHS guidelines
BP target 140/90mmHg, or 130/80 if ACR > 70mg/mmol
As above +
U & E’s 6 monthly (and Hb in CKD 3b),§
Cholesterol 12 monthly.
Parathormone (PTH) only if complicated CKD and
not otherwise referred#
Immunise against influenza and pneumococcus
Avoid nephrotoxic drugs if possible
Suggested Renal Referral
BP > 140/90 on 4 agents
Creatinine rise of 25% over 3 years (re test
on fasting sample to confirm)
Isolated microscopic haematuria < 50 years
ACR >70 mg/mmol
Micro haematuria and ACR > 30 mg/mmol
Suspected systemic illness
ARF with ACE-I (having stopped)
As above or
eGFR fall > 5mls a year (re test on fasting
sample to confirm)
Complicated CKD (unexplained anaemia, Ca,
PO4, bicarbonate abn, weight loss)
As above +
U & E’s 3 monthly for stage 4, 6 weekly for stage 5§
Ca, PO4, Bicarb, ALP, Alb, Haemoglobin, 3-6 monthly
PTH and ferritin 6 monthly if previous abnormal, 12
monthly if normal
Generally refer all patients. Possible
exceptions may be:
Dietary assessment
Immunise against Hep B if appropriate
Treat elevated PTH according to guidelines
Stable disease and no symptoms or
complications of renal failure
Renal replacement / conservative management option
education
In final terminal stages of another illness
Further investigation or management is
clearly inappropriate
Pre transplant assessment if appropriate
** 3 months proteinuria or microalbuminuria
Persistent haematuria after urology investigations
Biopsy proven glomerulonephritis
Structural abnormality of kidney or ureter
If none of the previous criteria
are evident, the patient is not
defined as CKD – no further
action required.
‡ Smoking cessation
weight reduction
aerobic exercise
limiting alcohol & salt intake
§ Repeat in 5
days if no
previous results
or ? acute fall
# PTH: CKD 3 not
measured as screenonly if complications.
CKD 4 requires test.
Proteinuria
Creatinine measurement Guidelines
Initial assessment and at least annually in the following groups
Avoid eating meat for 12 hours before a formal eGFR sample
Previously diagnosed CKD
Renal pathology (eg GN, APKD, reflux, single kidney)
Persistent proteinuria or haematuria
High risk of silent obstruction
Bladder voiding dysfunction, prostatic hypertrophy
Urinary diversion surgery, long term ureteric stents
Urinary stone disease (> 1 episode/year)
High risk of silent renal parenchymal disease
Hypertension, CCF, DM, IHD, CVD, PVD
FH of CKD stage 5 or hereditary kidney disease
Long term potentially nephrotoxic medication
ACE-I, A2RB, NSAIDS, lithium, mesalazine
ciclosporin, tacrolimus
Multisystem disease that may affect the kidney
SLE, vasculitis, myeloma, rheumatoid arthritis
Patients to be tested: eGFR < 60mls/min, +ve protein on urine dipstix,
diabetic screen.
ACR 30 – 70 mg/mmol - retest with early morning sample
> 30 mg/mmol on retest – significant for non diabetics
>2.5 for men and >3.5 for women with diabetes significant
Use suffix “p” when staging CKD (>30mg/mmol)
Haematuria
Urine dipstix. Does not need microscopy confirmation. 1+ significant.
Confirm with 2 out of 3 positive results.
Macroscopic haematuria to urology
Urology for isolated invisible haematuria if normal renal function and
> 50yrs, otherwise discuss with renal.
Renal ultrasound
Initiation of ACE-I / A2RB Guidelines
Start ACE-I / A2RB
Progressive CKD
Persistent invisible haematuria
Symptoms of obstruction
Visible haematuria
FH of APKD when >20 yrs
CKD stage 4 or 5
Considered to require a renal biopsy
Repeat eGFR at 2 weeks
Referrals and Information
Baseline eGFR within 4 weeks
Emergency Admissions:
eGFR < 5mls/min
fall
eGFR 5-15mls/min
fall
eGFR > 25%
fall
Urgent Referrals:
Continue
Stable
eGFR
Continue
and rpt eGFR
in 4 weeks
Stop and
refer to
nephrology
Continuing
decline
K+ > 6.0 – stop treatment and discuss with nephrology
Malignant hypertension
Potassium > 7 mmol/L
Acute severe illness with urine blood + protein
Acute renal failure
Nephrotic syndrome
Acute renal failure (not requiring admission)
BP > 170/100 mmHg
Systemic illness with urine blood + protein
We are happy to discuss any renal case. Please telephone the renal secretaries at
Treliske. We also would like to be notified of any significant event affecting any
dialysis or transplant patient.
Suggested web site for information: www.renal.org or www.renalpatientview.org