Chronic Kidney Disease - Adult Leeds

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1 Background Information / Scope of Pathway

Quick info:
The content of this pathway has been agreed and approved by the Dept of Renal Sevices (LTHT) and the Leeds CCGs. Clinical content has been provided by Dr Emma Dunn, Consultant in Renal Services (LTHT)

Chronic Kidney Disease (CKD) is now staged according to the estimated Glomerular Filtration Rate (eGFR), which is calculated from the age, sex and serum creatinine measurement by the chemical pathology laboratory. The laboratory value should be multiplied by 1.21 if the patient is black.

Detailed advice on management of metabolic acidosis is beyond the scope of this guideline. If uncertain, seek advice from local renal service.

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2 Information Resource for Patients and Carers

Quick info:
Acute Kidney Injury Patient Information Leaflet
Chronic Kidney Disease Patient Information Leaflet
Keep Kidneys Healthy Patient Information Leaflet

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3 Development and Updates to this Pathway

Quick info:
Pathway developed: March 2016
Pathway Review due: March 2018

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4 Training and Further Resources

Quick info:
Classification of CKD according to eGFR
Interpreting Proteinuria Poster

Chronic Kidney Disease: Screening Poster
Albumin: Creatinine Assessment in CKD and Diabetes

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5 Identification of Chronic Kidney Disease (CKD)

Quick info:
Abnormal kidney function, proteinuria or haematuria are common in everyday practice. It is important to identify which patients need special investigations or regular monitoring in primary care.

Whether it is a reduced eGFR or an abnormality of urine testing which comes to light first, both tests need to be undertaken (i.e. eGFR and urine testing) to enable assessment of whether patient needs referral for further assessment. There is a 10% decline in eGFR per decade of life from the age of 40 years.

Offer people testing for CKD annually (eGFR and ACR) if they have any of the following risk factors:

  • Hypertension
  • Diabetes mellitus
  • Cardiovascular disease
  • Heart Failure
  • Any condition requiring treatment with ACEi, ARB or diuretics
  • Structural renal disease, renal calculi or prostatic hypertrophy
  • Multi-system disease with potential kidney involvement (e.g. SLE, myeloma, rheumatoid arthritis)
  • Nephrotoxic drugs (e.g. NSAID, lithium calcineurin inhibitors etc.)
  • Family history of stage 5 CKD or hereditary kidney disease
  • Haematuria/proteinuria (opportunistically detected) See attached Classification of CKD according to eGFR

Testing for Proteinuria

  • Use albumin creatinine ratio (ACR) in preference to reagent strips and protein creatinine ratio (PCR)
  • If initial ACR is   30mg/mmol, confirm by a subsequent early morning sample. If initial ACR   70mg/mmol a repeat sample is not needed.
  • In people without diabetes consider clinically significant proteinuria to be present when ACR   30mg/mmol
  • In people with diabetes consider microalbuminuria (ACR > 2.5mg/mmol in men and >3.5.mg/mmol in women) to be clinically significant
    Interpreting Proteinuria Poster

Potassium Level

  • If serum potassium is above normal range (>5.5mmol/l):
    • do not start ACEi/ARBs
    • exclude and treat other factors that promote hyperkalaemia and recheck serum potassium (ensure no delay in centrifugation)
  • If also taking drugs that promote hyperkalaemia, more frequent monitoring of serum potassium may be required with ACEi/ ARBs
  • If serum potassium rises to   6.0mmol/l, stop drugs that may be contributing, e.g. NSAIDs, potassium-retaining diuretics, and check diet (especially 'LoSalt' which is potassium chloride.) If hyperkalaemia persists the ACEi or ARB should be stopped.

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6 Assessment

Quick info:

  • Review all previous creatinine/eGFR results to assess rates of deterioration
  • Assess clinically: for urinary symptoms, BP, sepsis, heart failure
  • Assess for symptoms/signs of obstructive pathology - arrange ultrasound of renal tract if no recent imaging available
  • Review medication, particularly recent additions e.g. non-steroidal anti-inflammatory drugs (NSAIDs), antibiotics, diuretics, ACEi/ARBs
  • Test urine for haematuria and proteinuria and send samples for proteinuria quantification (albumin creatinine ratio: ACR) on all patients
  • Check FBC, U&E, calcium, albumin, cholesterol

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7 Isolated Asymptomatic Microscopic Haematuria

Quick info:
Isolated invisible haematuria:

  • When testing for the presence of haematuria, use reagent strips rather than urine microscopy.
  • Evaluate further if there is a result of 1+ or more.
  • Do not use urine microscopy to confirm a positive result.

Managing isolated invisible haematuria

  • When there is the need to differentiate persistent invisible haematuria in the absence of proteinuria from transient haematuria, regard 2 out of 3 positive reagent strip tests as confirmation of persistent invisible haematuria.
  • Persistent invisible haematuria, with or without proteinuria, should prompt investigation for urinary tract malignancy in appropriate age groups.
  • Persistent invisible haematuria in the absence of proteinuria should be followed up annually with repeat testing for haematuria, proteinuria or albuminuria, GFR and blood pressure monitoring as long as the haematuria persists.

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9 Refer Nephrology

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Urgent referral:

  • Malignant hypertension
  • Acute kidney injury. Immediate referral/discussion for most patients with AKI unless the cause and solution are obvious (e.g. patient in retention who needs a urinary catheter; if so, admit under urology)
  • Nephrotic syndrome

Distinguishing AKI and CKD - Most patients with Acute Kidney Injury (AKI) look unwell, may have hyperkalaemia (potassium > 6.0 mmol/L), and usually need admission or rapid review according to the guidance in the AKI Map of Medicine pathway. Patients with CKD usually look well, and may have other complications of CKD (e.g. anaemia, low calcium, high PTH etc.) If hyperkalaemic, they may also need admission or rapid review. AKI complicating CKD is not uncommon, can have a mixture of all these features, and should be managed as AKI (see AKI pathway)

Information that is valuable to send with referral:

  • General medical history - particularly noting urinary symptoms, previous blood pressures, urine testing
  • Medication history
  • Examination
  • Urine dipstick result for haematuria and quantitation of proteinuria by ACR or PCR
  • Blood tests. Full blood count, urea and electrolytes. HbA1c if diabetic. If available, calcium, albumin, phosphate, cholesterol, PTH
  • Previous tests of renal function with dates (especially if done in centres other than LTHT)
  • Imaging - results of renal ultrasound if undertaken (pre-ordering may speed assessment)

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/1.73m2 (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 a sustained decrease in GFR of 15 ml/ min/1.73m2 or more within the preceding 12 month period
  • hypertension that remains poorly controlled despite the use of at least 4 antihypertensive drugs at therapeutic doses
  • known or suspected rare or genetic causes of CKD
  • suspected renal artery stenosis.

Consider discussing management issues with a specialist by letter, email, telephone or advice and guidance system 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. 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

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10 Management in Primary Care

Quick info:
General Measures to reduce associated cardiovascular risk:

  • Advice on weight management, exercise, stopping smoking, alcohol intake, low salt diet (avoid salt substitutes e.g. LoSalt)
  • Control blood pressure
    • In people with CKD aim to keep systolic blood pressure below 140mmHg (target range 120-139mmHg) and diastolic blood pressure below 90mmHg.
    • In people with CKD and diabetes, and also in people with an ACR of 70mg/mmol or more, aim to keep systolic blood pressure below 130mmHg (target range 120-129mmHg) and diastolic blood pressure below 80mmHg.
    • Consider aiming for BP below 150/90mmHg in people aged 80 years and over.
    • ACEi - first line (or ARB if ACEi intolerant)
    • Suggest patient buys own monitor
    • Refer to nephrology if BP >150/90 despite 4 agents
  • Use statins for primary prevention of cardiovascular disease in same way as patients without CKD
  • Offer statins for secondary prevention of cardiovascular disease irrespective of baseline lipid values
  • Consider prescribing Aspiring for secondary prevention of cardiovascular disease

Influenza /pneumococcal vaccination in stage 3-5 CKD
Review medication and dosages - avoid NSAID if possible

Specific Measures:
Stage 1&2 - monitor renal function annually (eGFR and PCR)
Stage 3 - monitor renal function (eGFR and ACR) and FBC six monthly
(Routine requests for PTH not recommended in primary care)
Arrange USS of renal tract to all patients with CKD who have:

  • progressive CKD
  • visible or persistent microscopic haematuria
  • symptoms of bladder outflow obstruction
  • have family history of polycystic kidney disease and >20 years old
  • stage 4/5 CKD

Safe use of ACEi and ARB

  • Measure serum potassium concentrations and estimate eGFR before starting renin–angiotensin system antagonists. Repeat 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  pre-treatment serum potassium concentration > 5.5mmol/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 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 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 GFR decrease from pre-treatment baseline < 25% or serum creatinine increase from baseline < 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 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 deterioration in renal function (volume depletion or concurrent medication (for example, NSAIDs)) if no other cause for the deterioration in renal function, stop the renin–angiotensin system antagonist or reduce dose to previously tolerated lower dose, and add alternative antihypertensive medication if required.

Vitamin D supplements in management of CKD–mineral and bone disorders
If uncertain, seek advice from your local renal service about management of CKD–mineral and bone disorders

  • Do not routinely offer vitamin D supplementation to manage/prevent CKD–mineral and bone disorders.
  • Offer colecalciferol or ergocalciferol to treat vitamin D deficiency in people with CKD and vitamin D deficiency.
  • If vitamin D deficiency has been corrected and CKD–mineral and bone disorders persist, offer alfacalcidol (1-alpha- hydroxycholecalciferol) or calcitriol (1-25-dihydroxycholecalciferol) to people with GFR of less than 30ml/min/1.73m2 (GFR category G4 or G5).
  • Monitor serum calcium and phosphate concentrations in people receiving alfacalcidol or calcitriol supplements.

Oral bicarbonate supplements in the management of metabolic acidosis

  • Consider oral sodium bicarbonate supplementation for people with both:  GFR < 30 ml/min/1.73m2 (GFR category G4 or G5) and serum bicarbonate concentration < 20mmol/litre.

Self-management
Ensure systems are in place to:

  • inform diagnosis
  • enable shared decision-making
  • support self-management (provide information about blood pressure, smoking cessation, exercise, diet, medicines)
  • enable informed choices
    Give people access to their medical data to help them self manage.

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11 Refer Nephrology

Quick info:
Urgent referral:

  • Malignant hypertension
  • Acute kidney injury. Immediate referral/discussion for most patients with AKI unless the cause and solution are obvious (e.g. patient in retention who needs a urinary catheter; if so, admit under urology)
  • Nephrotic syndrome

Distinguishing AKI and CKD - Most patients with Acute Kidney Injury (AKI) look unwell, may have hyperkalaemia (potassium > 6.0 mmol/L), and usually need admission or rapid review according to the guidance in the AKI Map of Medicine pathway. Patients with CKD usually look well, and may have other complications of CKD (e.g. anaemia, low calcium, high PTH etc.) If hyperkalaemic, they may also need admission or rapid review. AKI complicating CKD is not uncommon, can have a mixture of all these features, and should be managed as AKI (see AKI pathway)

Information that is valuable to send with referral:

  • General medical history - particularly noting urinary symptoms, previous blood pressures, urine testing
  • Medication history
  • Examination
  • Urine dipstick result for haematuria and quantitation of proteinuria by ACR or PCR
  • Blood tests. Full blood count, urea and electrolytes. HbA1c if diabetic. If available, calcium, albumin, phosphate, cholesterol, PTH
  • Previous tests of renal function with dates (especially if done in centres other than LTHT)
  • Imaging - results of renal ultrasound if undertaken (pre-ordering may speed assessment)

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/1.73m2 (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 a sustained decrease in GFR of 15 ml/
    min/1.73m2 or more within the preceding 12 month period
  • hypertension that remains poorly controlled despite the use of at least 4 antihypertensive drugs at therapeutic doses
  • known or suspected rare or genetic causes of CKD
  • suspected renal artery stenosis.

Consider discussing management issues with a specialist by letter, email, telephone or advice and guidance system 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. 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

Key Dates

Published: 16-Mar-2016, by Leeds
Valid until: 31-Mar-2018

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