History:

Reviewed Pre-consultation Patient Questionnaire? 

Risk factors for CKD?

Raised serum creatinine?

eGFR < 60 ml/min/1.73 m2?

Urine ACR > 3 mg/mmol?

Persistent haematuria (two or of three urine dipstick tests show 1+ or more of blood) after exclusion of a urinary tract infection (UTI)?

- Urine sediment abnormalities:

--- Red blood cells (may indicate glomerular disease)?

--- White blood cells (may indicate pyelonephritis or interstitial nephritis)?

--- Granular casts and renal tubular epithelial cells (seen in many parenchymal diseases)?

Possible clinical features of CKD? 

Examination:

Nutritional status (eg cachexia or signs of malnutrition)?

Uraemic odour (ammonia-like smell or the breath, may be present in advanced disease)?

Pallor?

Dehydration or hypovolaemia?

Height?

Weight?

BMI? 

RR?

BP?

Palpable (bilateral) flank masse(s)?

Hepatomegaly?

Palpable distended bladder?

Peripheral oedema?

Peripheral neuropathy:

- Paraesthesia?

- Restless legs syndrome?

- Sleep disturbance?

Cognitive impairment:

- Language?

- Orientation?

- Attention?

Frothy urine?

Investigations:

Checked if required lab results were available and requested them if outstanding?

Serum creatinin and estimated glomerular filtration rate (eGFR)

(Not to eat meat for at least 12 hours before the test) 

< 60 ml/min/1.73 m2?

- If yes, repeat the test within 2 weeks (unless the eGFR is stable)

< 60 ml/min/1.73 m2 on repeat + no evidence of sudden deterioration in renal function suggesting acute kidney injury?

- If yes, repeat eGFR in 3 months

(Note: interpret the eGFR result with caution if the person has extremes of muscle mass, is pregnant, has oedema, is malnourished or uses protein supplements, or is Asian or Chinese in origin)

Early morning urine sample for urinary ACR?

< 3 mg/mmol (no proteinuria)?

- If yes, no action needed

3-70 mg/mmol?

- If yes, repeat within 3 months

≥ 70 mg/mmol or more?

- If yes, repeat test not needed as indicative of significant proteinuria (see management in primary care)

(Note: transient increases in urine ACR may be seen with menstruation, urinary tract infection (UTI), strenuous exercise, and upright posture ('orthostatic proteinuria'))

Urine dipstick test to check for haematuria:

1+ or more of blood?

- If yes, mid-stream urine sample (MSU) to exclude a UTI

If isolated persistent haematuria (two out of three urine dipstick tests show 1+ or more of blood after exclusion of a UTI) with no decrease in eGFR and no proteinuria?

- If yes, see Urological cancers - recognition and referral

eGFR and urine ACR repeat within 3 months:

eGFR < 60 mL/min/1.73 m2) and/or proteinuria (urinary ACR > 3 mg/mmol) lasting for at least 3 months?

- If yes, diagnosis of CKD (classification of CKD) (Note: a significant increase in serum creatinine, for example by more than 20%, may indicate significant renal impairment, in the presence of normal eGFR readings (eGFR greater than 90 mL min/1.73 m2))

Other:

HbA1c?

Lipid profile?

Renal tract ultrasound if indicated (eg suspected urinary tract stones or obstruction or a family history of polycystic kidney disease and is aged over 20 years)?

CKD category stages 3b, 4, and 5 (or if a person develops symptoms suggestive of anaemia)?

Full blood cell count (FBC)?

CKD Category stages 4 or 5?

Serum calcium?

Phosphate?

Vitamin D?

Parathyroid hormone?

Management:

Identification of underlying causes and risk factors? 

Monitoring (serum creatinine, eGFR, urinary ACR)?

(Note: frequency of eGFR monitoring (number of times per year) for people with or at risk of CKD)

'Accelerated progression' (sustained decrease in eGFR of ≥ 25% from baseline and a change in CKD category within 12 months; or a sustained decrease in eGFR of ≥ 15 mL/min/1.73 m2 within 12 months)? 

(Note: To assess the rate of progression, repeat eGFR 3 times over at least 3 months) 

If present:

- Assessment for any reversible cause (such as potentially nephrotoxic drugs or volume depletion)?

- Renal tract ultrasound scan?

- Referral to a nephrology specialist?

Risk of acute kidney injury (AKI)?

- Consideration of stopping nephrotoxic drugs?

- Monitoring for a least 2-3 years (even if serum creatinine had returned to baseline) after an episode of acute kidney injury (AKI)?

BP within target?

CKD and an ACR < 70 mg/mmol?

< 140/90 mmHg (target systolic range 120 to 139 mmHg)?

CKD and an ACR ≥ 70 mg/mmol and/or diabetes?

< 130/80 mmHg (target systolic range 120 to 129 mmHg)?

Diabetic adults ≥ 80 years + whatever urinary ACR?

BP < 150/90 mmHg (target systolic range 140 to 149 mmHg)?

Hypertension + urinary ACR ≥ 30 mg/mmol?

Renin–angiotensin system (RAS) antagonist (lisinopril or losartan) (titrated to the highest licensed dose that the person can tolerate)?

Diabetes + urinary ACR ≥ 30 mg/mmol?

Renin–angiotensin system (RAS) antagonist (titrated to the highest licensed dose that the person can tolerate)?

ACR ≥ 70 mg/mmol (irrespective of hypertension or cardiovascular disease)?

Renin–angiotensin system (RAS) (eg lisinopril or losartan)?

(Notes: RAS antagonists: potassium + eGFR before start in people with CKD and between 1 and 2 weeks after and after each dose increase

Potassium > 5.0 mmol/litre: do not routinely offer RAS antagonist

Potassium > 6.0 mmol/litre: stop if RAS antagonist

If decrease in eGFR or increase in serum creatinine after starting or increasing the dose of RAS antagonists, but < 25% (eGFR) or 30% (serum creatinine) of baseline, repeat the test in 1–2 weeks, do not modify the RAS antagonist dose if the change in eGFR is < 25% or the change in serum creatinine is < 30%)

Statin:

Atorvastatin 20 mg offered?

Increased if a greater than 40% reduction in non-HDL cholesterol is not achieved and eGFR is ≥ 30 ml/min/1.73 m2?

Agreed the use of higher doses with a renal specialist if eGFR < 30 ml/min/1.73 m2 (renal impairment risk factor for myopathy and rhabdomyolysis adverse effects of statins)?

Dapagliflozin:

Considered dapagliflozin unless contraindicated if eGFR of 25-75 ml/min/1.73 m2 at the start of the treatment and type 2 diabetes and/or ACR ≥ 22.6 mg/mmol?

Vaccinations:

Offered influenza immunization?

Offered pneumococcal immunization?

5-year risk:

Informed about 5-year risk of needing renal replacement therapy (measured using the 4-variable Kidney Failure Risk Equation)?

Chronic Kidney Disease (CKD) - General Patient Information explained and provided to patient?

Advised:

About 5-year risk of needing renal replacement therapy (measured using the 4-variable Kidney Failure Risk Equation)?

Stop smoking if appropriate

Drink alcohol in moderation

Maintain a healthy body weight

Eat a healthy diet

Take regular exercise

Avoid the use of over-the-counter non steroidal anti-inflammatory drugs (NSAIDS) where possible

Avoid herbal remedies

Use protein supplements with caution

Increased risk of acute kidney injury (AKI)

Provided sources of information, advice and support:

- Kidney Care UK (website available at www.kidneycareuk.org), national kidney charity with telephone support helpline (telephone 01420 541424) and several leaflets on CKD and associated conditions

- NHS info 'Chronic kidney disease’

- Patient UK info 'Chronic kidney disease'

Referral:

2-week referral:

Isolated persistent haematuria and suspicion of urological cancer?

Referral to nephrologist:

A 5-year risk of needing renal replacement therapy of greater than 5% (measured using the 4-variable Kidney Failure Risk Equation)?

Accelerated progression of CKD?

Urinary ACR ≥ 70 mg/mmol, unless proteinuria known to be associated with diabetes mellitus and is managed appropriately?

Urinary ACR ≥ 30 mg/mmol with persistent haematuria, after exclusion of a urinary tract infection (UTI)?

Hypertension that remains uncontrolled despite the use of at least four antihypertensive drugs at therapeutic doses?

A suspected or confirmed rare or genetic cause of CKD, such as polycystic kidney disease?

Suspected renal artery stenosis (should be suspected if there is a greater than 25% reduction in eGFR within 3 months of starting (or increasing the dose of) a renin-angiotensin system antagonist, refractory hypertension, pulmonary oedema, and/or a renal artery bruit)?

Complications of CKD?

Referral to urologist:

Suspected urinary tract obstruction?

Chronic kidney disease (CKD) - General Patient Information explained and provided to patient?

Resource(s):

NICE CKS: Chronic kidney disease. May 2023