Evaluation and Management of Chronic Kidney Disease

Publication Date: January 1, 2013

Recommendation Statements

Definition and classification of CKD

DEFINITION OF CKD

CKD is defined as abnormalities of kidney structure or function, present for 43 months, with implications for health. (NG)
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STAGING OF CKD

We recommend that CKD is classified based on cause, GFR category, and albuminuria category (CGA). (Level 1, B)
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Assign cause of CKD based on presence or absence of systemic disease and the location within the kidney of observed or presumed pathologic-anatomic findings. (NG)
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Assign GFR categories as follows: (NG)
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GFR categories in CKD
GFR category GFR category Terms
G1 ≥90 Normal or high
G2 60-89 Mildly decreased (Relative to young adult level)
G3a 45-59 Mildly to moderately decreased
G3b 30-44 Moderately to severely decreased
G4 15-29 Severely decreased
G5 <15 Kidney failure
Assign albuminuria categories (relative to young adult level) as follows: (NG, )
Note that where albuminuria measurement is not available, urine reagent strip results can be substituted.
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Albuminuria categories in CKD
albumin-to-creatinine ratio (ACR) (approximate equivalent)
Category albumin excretion rate (AER)(mg/24 hours) (mg/mmol) (mg/g) Terms
A1 <30 <3 <30 Normal to mildly increased
A2 30-300 3-30 30-300 Moderately increased (relative to young adult level)
A3 >300 >30 >300 Severely increased (including nephrotic syndrome (albumin excretion usually >2200 mg/24 hours [ACR >2220 mg/g; >220 mg/mmol])

PREDICTING PROGNOSIS OF CKD

In predicting risk for outcome of CKD, identify the following variables: 1) cause of CKD; 2) GFR category; 3) albuminuria category; 4) other risk factors and comorbid conditions. (NG)
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In people with CKD, use estimated risk of concurrent complications and future outcomes to guide decisions for testing and treatment for CKD complications. (NG)
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In populations with CKD, group GFR and albuminuria categories with similar relative risk for CKD outcomes into risk categories. (NG)
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EVALUATION OF CKD

Evaluation of chronicity

In people with GFR <60 ml/min/1.73 m2 (GFR categories G3a-G5) or markers of kidney damage, review past history and previous measurements to determine duration of kidney disease.
  • If duration is >3 months, CKD is confirmed. Follow recommendations for CKD.
  • If duration is not >3 months or unclear, CKD is not confirmed. Patients may have CKD or acute kidney diseases (including AKI) or both and tests should be repeated accordingly.
(NG)
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Evaluation of cause

Evaluate the clinical context, including personal and family history, social and environmental factors, medications, physical examination, laboratory measures, imaging, and pathologic diagnosis to determine the causes of kidney disease. (NG)
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Evaluation of GFR

We recommend using serum creatinine and a GFR estimating equation for initial assessment. (Level 1, A)
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We suggest using additional tests (such as cystatin C or a clearance measurement) for confirmatory testing in specific circumstances when eGFR based on serum creatinine is less accurate. (Level 2, B)
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We recommend that clinicians:
  • use a GFR estimating equation to derive GFR from serum creatinine (eGFRcreat) rather than relying on the serum creatinine concentration alone.
  • understand clinical settings in which eGFRcreat is less accurate.
(Level 1, B)
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We recommend that clinical laboratories should (1B):
  • measure serum creatinine using a specific assay with calibration traceable to the international standard reference materials and minimal bias compared to isotope-dilution mass spectrometry (IDMS) reference methodology.
  • report eGFRcreat in addition to the serum creatinine concentration in adults and specify the equation used whenever reporting eGFRcreat.
  • report eGFRcreat in adults using the 2009 CKD-EPI creatinine equation. An alternative creatinine-based GFR estimating equation is acceptable if it has been shown to improve accuracy of GFR estimates compared to the 2009 CKD-EPI creatinine equation.
When reporting serum creatinine:
  • We recommend that serum creatinine concentration be reported and rounded to the nearest whole number when expressed as standard international units (lmol/l) and rounded to the nearest 100th of a whole number when expressed as conventional units (mg/dl).
When reporting eGFRcreat:
  • We recommend that eGFRcreat should be reported and rounded to the nearest whole number and relative to a body surface area of 1.73 m2 in adults using the units ml/min/1.73 m2 .
  • We recommend eGFRcreat levels less than 60 ml/min/1.73 m2 should be reported as ‘‘decreased.’’
(Level 1, B)
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We suggest measuring cystatin C in adults with eGFRcreat 45–59 ml/min/1.73 m2 who do not have markers of kidney damage if confirmation of CKD is required.
  • If eGFRcys/eGFRcreat-cys is also <60 ml/min/1.73 m2 , the diagnosis of CKD is confirmed.
  • If eGFRcys/eGFRcreat-cys is ≥60 ml/min/1.73 m2, the diagnosis of CKD is not confirmed.
(Level 2, C)
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If cystatin C is measured, we suggest that health professionals:
  • use a GFR estimating equation to derive GFR from serum cystatin C rather than relying on the serum cystatin C concentration alone.
  • understand clinical settings in which eGFRcys and eGFRcreat-cys are less accurate.
(Level 2, C)
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We recommend that clinical laboratories that measure cystatin C should:
  • measure serum cystatin C using an assay with calibration traceable to the international standard reference material.
  • report eGFR from serum cystatin C in addition to the serum cystatin C concentration in adults and specify the equation used whenever reporting eGFRcys and eGFRcreat-cys.
  • report eGFRcys and eGFRcreat-cys in adults using the 2012 CKD-EPI cystatin C and 2012 CKD-EPI creatinine-cystatin C equations, respectively, or alternative cystatin C-based GFR estimating equations if they have been shown to improve accuracy of GFR estimates compared to the 2012 CKD-EPI cystatin C and 2012 CKD-EPI creatinine-cystatin C equations.
When reporting serum cystatin C:
  • We recommend reporting serum cystatin C concentration rounded to the nearest 100th of a whole number when expressed as conventional units (mg/l).
When reporting eGFRcys and eGFRcreat-cys:
  • We recommend that eGFRcys and eGFRcreat-cys be reported and rounded to the nearest whole number and relative to a body surface area of 1.73 m2 in adults using the units ml/min/1.73 m2 .
  • We recommend eGFRcys and eGFRcreat-cys levels less than 60 ml/min/1.73 m2 should be reported as ‘‘decreased.’’
(Level 1, B)
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We suggest measuring GFR using an exogenous filtration marker under circumstances where more accurate ascertainment of GFR will impact on treatment decisions. (Level 2, B)
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Evaluation of albuminuria

We suggest using the following measurements for initial testing of proteinuria (in descending order of preference, in all cases an early morning urine sample is preferred):
1) urine albumin-to-creatinine ratio (ACR)
2) urine protein-to-creatinine ratio (PCR)
3) reagent strip urinalysis for total protein with automated reading
4) reagent strip urinalysis for total protein with manual reading.
(Level 2, B)
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We recommend that clinical laboratories report ACR and PCR in untimed urine samples in addition to albumin concentration or proteinuria concentrations rather than the concentrations alone. (Level 1, B)
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The term microalbuminuria should no longer be used by laboratories. (NG)
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Clinicians need to understand settings that may affect interpretation of measurements of albuminuria and order confirmatory tests as indicated:
  • Confirm reagent strip positive albuminuria and proteinuria by quantitative laboratory measurement and express as a ratio to creatinine wherever possible.
  • Confirm ACR≥30 mg/g (≥3 mg/mmol) on a random untimed urine with a subsequent early morning urine sample.
  • If a more accurate estimate of albuminuria or total proteinuria is required, measure albumin excretion rate or total protein excretion rate in a timed urine sample.
(NG)
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If significant non-albumin proteinuria is suspected, use assays for specific urine proteins (e.g., α1-microglobulin, monoclonal heavy or light chains, [known in some countries as ‘‘Bence Jones’’ proteins]). (NG)
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Definition, identification, and prediction of CKD progression

DEFINITION AND IDENTIFICATION OF CKD PROGRESSION

Assess GFR and albuminuria at least annually in people with CKD. Assess GFR and albuminuria more often for individuals at higher risk of progression, and/or where measurement will impact therapeutic decisions. (NG)
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Recognize that small fluctuations in GFR are common and are not necessarily indicative of progression. (NG)
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Define CKD progression based on one of more of the following:
  • Decline in GFR category (≥90 [G1], 60–89 [G2], 45–59 [G3a], 30–44 [G3b], 15–29 [G4], <15 [G5] ml/min/ 1.73 m2 ). A certain drop in eGFR is defined as a drop in GFR category accompanied by a 25% or greater drop in eGFR from baseline.
  • Rapid progression is defined as a sustained decline in eGFR of more than 5 ml/min/1.73 m2 /yr.
  • The confidence in assessing progression is increased with increasing number of serum creatinine measurements and duration of follow-up.
(NG)
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In people with CKD progression, review current management, examine for reversible causes of progression, and consider referral to a specialist. (NG)
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PREDICTORS OF PROGRESSION

Identify factors associated with CKD progression to inform prognosis. These include cause of CKD, level of GFR, level of albuminuria, age, sex, race/ethnicity, elevated BP, hyperglycemia, dyslipidemia, smoking, obesity, history of cardiovascular disease, ongoing exposure to nephrotoxic agents, and others. (NG)
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Management of progression and complications of CKD

PREVENTION OF CKD PROGRESSION

BP and RAAS interruption
Individualize BP targets and agents according to age, coexistent cardiovascular disease and other comorbidities, risk of progression of CKD, presence or absence of retinopathy (in CKD patients with diabetes), and tolerance of treatment as described in the KDIGO 2012 Blood Pressure Guideline. (NG)
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Inquire about postural dizziness and check for postural hypotension regularly when treating CKD patients with BP-lowering drugs. (NG)
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Tailor BP treatment regimens in elderly patients with CKD by carefully considering age, comorbidities and other therapies, with gradual escalation of treatment and close attention to adverse events related to BP treatment, including electrolyte disorders, acute deterioration in kidney function, orthostatic hypotension and drug side effects. (NG)
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We recommend that in both diabetic and non-diabetic adults with CKD and urine albumin excretion <30 mg/ 24 hours (or equivalent) whose office BP is consistently >140 mm Hg systolic or >90 mm Hg diastolic be treated with BP-lowering drugs to maintain a BP that is consistently ≤140 mm Hg systolic and ≤90 mm Hg diastolic. (Level 1, B)
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We suggest that in both diabetic and non-diabetic adults with CKD and with urine albumin excretion of >30 mg/24 hours (or equivalent) whose office BP is consistently >130 mm Hg systolic or >80 mm Hg diastolic be treated with BP-lowering drugs to maintain a BP that is consistently ≤130 mm Hg systolic and ≤80 mm Hg diastolic. (Level 2, D)
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We suggest that an ARB or ACE-I be used in diabetic adults with CKD and urine albumin excretion 30–300 mg/24 hours (or equivalent). (Level 2, D)
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We recommend that an ARB or ACE-I be used in both diabetic and non-diabetic adults with CKD and urine albumin excretion >300 mg/24 hours (or equivalent). (Level 1, B)
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There is insufficient evidence to recommend combining an ACE-I with ARBs to prevent progression of CKD. (NG)
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We recommend that in children with CKD, BP-lowering treatment is started when BP is consistently above the 90th percentile for age, sex, and height. (Level 1, C)
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We suggest that in children with CKD (particularly those with proteinuria), BP is lowered to consistently achieve systolic and diastolic readings less than or equal to the 50th percentile for age, sex, and height, unless achieving these targets is limited by signs or symptoms of hypotension. (Level 2, D)
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We suggest that an ARB or ACE-I be used in children with CKD in whom treatment with BP-lowering drugs is indicated, irrespective of the level of proteinuria. (Level 2, D)
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CKD and risk of AKI
We recommend that all people with CKD are considered to be at increased risk of AKI. (Level 1, A)
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In people with CKD, the recommendations detailed in the KDIGO AKI Guideline should be followed for management of those at risk of AKI during intercurrent illness, or when undergoing investigation and procedures that are likely to increase the risk of AKI. (NG)
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Protein intake
We suggest lowering protein intake to 0.8 g/kg/day in adults
  • with diabetes
(Level 2, C)
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  • without diabetes and GFR <30 ml/min/ 1.73 m2 (GFR categories G4-G5),
(Level 2, B)
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with appropriate education.
We suggest avoiding high protein intake (>1.3 g/kg/day) in adults with CKD at risk of progression. (Level 2, C)
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Glycemic control
We recommend a target hemoglobin A1c (HbA1c) of ~7.0% (53 mmol/mol) to prevent or delay progression of the microvascular complications of diabetes, including diabetic kidney disease. (Level 1, A)
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We recommend not treating to an HbA1c target of <7.0% (<53 mmol/mol) in patients at risk of hypoglycemia. (Level 1, B)
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We suggest that target HbA1c be extended above 7.0% (53 mmol/mol) in individuals with comorbidities or limited life expectancy and risk of hypoglycemia. (Level 2, C)
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In people with CKD and diabetes, glycemic control should be part of a multifactorial intervention strategy addressing blood pressure control and cardiovascular risk, promoting the use of angiotensin-converting enzyme inhibition or angiotensin receptor blockade, statins, and antiplatelet therapy where clinically indicated. (NG)
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Salt intake
We recommend lowering salt intake to <90 mmol (<2 g) per day of sodium (corresponding to 5 g of sodium chloride) in adults, unless contraindicated. (Level 1, C)
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We recommend restriction of sodium intake for children with CKD who have hypertension (systolic and/or diastolic blood pressure >95th percentile) or prehypertension (systolic and/or diastolic blood pressure >90th percentile and <95th percentile), following the age-based Recommended Daily Intake. (Level 1, C)
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We recommend supplemental free water and sodium supplements for children with CKD and polyuria to avoid chronic intravascular depletion and to promote optimal growth. (Level 1, C)
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Hyperuricemia
There is insufficient evidence to support or refute the use of agents to lower serum uric acid concentrations in people with CKD and either symptomatic or asymptomatic hyperuricemia in order to delay progression of CKD. (NG)
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Lifestyle
We recommend that people with CKD be encouraged to undertake physical activity compatible with cardiovascular health and tolerance (aiming for at least 30 minutes 5 times per week), achieve a healthy weight (BMI 20 to 25, according to country specific demographics), and stop smoking. (Level 1, D)
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Additional dietary advice
We recommend that individuals with CKD receive expert dietary advice and information in the context of an education program, tailored to severity of CKD and the need to intervene on salt, phosphate, potassium, and protein intake where indicated. (Level 1, B)
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COMPLICATIONS ASSOCIATED WITH LOSS OF KIDNEY FUNCTION

Definition and identification of anemia in CKD
Diagnose anemia in adults and children >15 years with CKD when the Hb concentration is <13.0 g/dl (<130 g/l) in males and <12.0 g/dl (<120 g/l) in females. (NG)
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Diagnose anemia in children with CKD if Hb concentration is <11.0 g/dl (<110 g/l) in children 0.5–5 years, <11.5 g/dl (115 g/l) in children 5–12 years, and <12.0 g/dl (120 g/l) in children 12-15 years. (NG)
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Evaluation of anemia in people with CKD
To identify anemia in people with CKD measure Hb concentration:
  • when clinically indicated in people with GFR ≥60 ml/min/1.73 m2 (GFR categories G1-G2)
  • at least annually in people with GFR 30–59 ml/min/1.73 m2 (GFR categories G3a-G3b)
  • at least twice per year in people with GFR <30 ml/min/1.73 m2 (GFR categories G4-G5).
(NG)
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CKD METABOLIC BONE DISEASE INCLUDING LABORATORY ABNORMALITIES

We recommend measuring serum levels of calcium, phosphate, PTH, and alkaline phosphatase activity at least once in adults with GFR <45 ml/min/1.73 m2 (GFR categories G3b-G5) in order to determine baseline values and inform prediction equations if used. (Level 1, C)
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We suggest not to perform bone mineral density testing routinely in those with eGFR <45 ml/min/1.73 m2 (GFR categories G3b-G5), as information may be misleading or unhelpful. (Level 2, B)
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In people with GFR <45 ml/min/1.73 m2 (GFR categories G3b-G5), we suggest maintaining serum phosphate concentrations in the normal range according to local laboratory reference values. (Level 2, C)
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In people with GFR <45 ml/min/1.73 m2 (GFR categories G3b-G5) the optimal PTH level is not known. We suggest that people with levels of intact PTH above the upper normal limit of the assay are first evaluated for hyperphosphatemia, hypocalcemia, and vitamin D deficiency. (Level 2, C)
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Vitamin D supplementation and bisphosphonates in people with CKD

We suggest not to routinely prescribe vitamin D supplements or vitamin D analogs, in the absence of suspected or documented deficiency, to suppress elevated PTH concentrations in people with CKD not on dialysis. (Level 2, B)
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We suggest not to prescribe bisphosphonate treatment in people with GFR <30 ml/min/1.73 m2 (GFR categories G4-G5) without a strong clinical rationale. (Level 2, B)
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ACIDOSIS

We suggest that in people with CKD and serum bicarbonate concentrations <22 mmol/l treatment with oral bicarbonate supplementation be given to maintain serum bicarbonate within the normal range, unless contraindicated. (Level 2, B)
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Other complications of CKD: CVD, medication dosage, patient safety, infections, hospitalizations, and caveats for investigating complications of CKD

CKD AND CVD

We recommend that all people with CKD be considered at increased risk for cardiovascular disease. (Level 1, A)
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We recommend that the level of care for ischemic heart disease offered to people with CKD should not be prejudiced by their CKD. (Level 1, A)
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We suggest that adults with CKD at risk for atherosclerotic events be offered treatment with antiplatelet agents unless there is an increased bleeding risk that needs to be balanced against the possible cardiovascular benefits. (Level 2, B)
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We suggest that the level of care for heart failure offered to people with CKD should be the same as is offered to those without CKD. (Level 2, A)
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In people with CKD and heart failure, any escalation in therapy and/or clinical deterioration should prompt monitoring of eGFR and serum potassium concentration. (NG)
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CAVEATS WHEN INTERPRETING TESTS FOR CVD IN PEOPLE WITH CKD

BNP/N-terminal-proBNP (NT-proBNP)
In people with GFR <60 ml/min/1.73 m2 (GFR categories G3a-G5), we recommend that serum concentrations of BNP/NT-proBNP be interpreted with caution and in relation to GFR with respect to diagnosis of heart failure and assessment of volume status. (Level 1, B)
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Troponins
In people with GFR <60 ml/min/1.73 m2 (GFR categories G3a-G5), we recommend that serum concentrations of troponin be interpreted with caution with respect to diagnosis of acute coronary syndrome. (Level 1, B)
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Non-invasive testing
We recommend that people with CKD presenting with chest pain should be investigated for underlying cardiac disease and other disorders according to the same local practice for people without CKD (and subsequent treatment should be initiated similarly). (Level 1, B)
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We suggest that clinicians are familiar with the limitations of non-invasive cardiac tests (e.g., exercise electrocardiography [ECG], nuclear imaging, echocardiography, etc.) in adults with CKD and interpret the results accordingly. (Level 2, B)
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CKD AND PERIPHERAL ARTERIAL DISEASE

We recommend that adults with CKD be regularly examined for signs of peripheral arterial disease and be considered for usual approaches to therapy. (Level 1, B)
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We suggest that adults with CKD and diabetes are offered regular podiatric assessment. (Level 2, A)
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MEDICATION MANAGEMENT AND PATIENT SAFETY IN CKD

We recommend that prescribers should take GFR into account when drug dosing. (Level 1, A)
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Where precision is required for dosing (due to narrow therapeutic or toxic range) and/or estimates may be unreliable (e.g., due to low muscle mass), we recommend methods based upon cystatin C or direct measurement of GFR. (Level 1, C)
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We recommend temporary discontinuation of potentially nephrotoxic and renally excreted drugs in people with a GFR <60 ml/min/1.73 m2 (GFR categories G3a-G5) who have serious intercurrent illness that increases the risk of AKI. These agents include, but are not limited to: RAAS blockers (including ACE-Is, ARBs, aldosterone inhibitors, direct renin inhibitors), diuretics, NSAIDs, metformin, lithium, and digoxin. (Level 1, C)
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We recommend that adults with CKD seek medical or pharmacist advice before using over-the-counter medicines or nutritional protein supplements. (Level 1, B)
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We recommend not using herbal remedies in people with CKD. (Level 1, B)
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We recommend that metformin be continued in people with GFR ≥45ml/min/1.73 m2 (GFR categories G1-G3a); its use should be reviewed in those with GFR 30–44ml/min/1.73 m2 (GFR category G3b); and it should be discontinued in people with GFR <30 ml/min/1.73 m2 (GFR categories G4-G5). (Level 1, C)
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We recommend that all people taking potentially nephrotoxic agents such as lithium and calcineurin inhibitors should have their GFR, electrolytes and drug levels regularly monitored. (Level 1, A)
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People with CKD should not be denied therapies for other conditions such as cancer but there should be appropriate dose adjustment of cytotoxic drugs according to knowledge of GFR. (NG)
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IMAGING STUDIES

Balance the risk of acute impairment in kidney function due to contrast agent use against the diagnostic value and therapeutic implications of the investigation. (NG)
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Radiocontrast

We recommend that all people with GFR <60 ml/min/1.73 m2 (GFR categories G3a-G5) undergoing elective investigation involving the intravascular administration of iodinated radiocontrast media should be managed according to the KDIGO Clinical Practice Guideline for AKI including:
  • Avoidance of high osmolar agents
(Level 1, B)
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  • Use of lowest possible radiocontrast dose
(NG)
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  • Withdrawal of potentially nephrotoxic agents before and after the procedure
(Level 1, C)
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  • Adequate hydration with saline before, during, and after the procedure
(Level 1, A)
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  • Measurement of GFR 48–96 hours after the procedure
(Level 1, C)
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Gadolinium-based contrast media
We recommend not using gadolinium-containing contrast media in people with GFR <15 ml/min/1.73 m2 (GFR category G5) unless there is no alternative appropriate test. (Level 1, B)
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We suggest that people with a GFR <30 ml/min/1.73 m2 (GFR categories G4-G5) who require gadoliniumcontaining contrast media are preferentially offered a macrocyclic chelate preparation. (Level 2, B)
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Bowel preparation
We recommend not to use oral phosphate-containing bowel preparations in people with a GFR <60 ml/min/ 1.73 m2 (GFR categories G3a-G5) or in those known to be at risk of phosphate nephropathy. (Level 1, A)
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CKD AND RISKS FOR INFECTIONS, AKI, HOSPITALIZATIONS, AND MORTALITY

CKD and risk of infections
We recommend that all adults with CKD are offered annual vaccination with influenza vaccine, unless contraindicated. (Level 1, B)
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We recommend that all adults with eGFR <30 ml/min/1.73 m2 (GFR categories G4-G5) and those at high risk of pneumococcal infection (e.g., nephrotic syndrome, diabetes, or those receiving immunosuppression) receive vaccination with polyvalent pneumococcal vaccine unless contraindicated. (Level 1, B)
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We recommend that all adults with CKD who have received pneumococcal vaccination are offered revaccination within 5 years. (Level 1, B)
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We recommend that all adults who are at high risk of progression of CKD and have GFR <30 ml/min/1.73 m2 (GFR categories G4-G5) be immunized against hepatitis B and the response confirmed by appropriate serological testing. (Level 1, B)
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Consideration of live vaccine should include an appreciation of the patient’s immune status and should be in line with recommendations from official or governmental bodies. (NG)
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Pediatric immunization schedules should be followed according to official international and regional recommedations for children with CKD. (NG)
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CKD and risk of AKI
We recommend that all people with CKD are considered to be at increased risk of AKI. (Level 1, A)
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In people with CKD, the recommendations detailed in the KDIGO AKI Guideline should be followed for management of those at risk of AKI during intercurrent illness, or when undergoing investigation and procedures that are likely to increase the risk of AKI. (NG)
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CKD and risk of hospitalization and mortality
CKD disease management programs should be developed in order to optimize the community management of people with CKD and reduce the risk of hospital admission. (NG)
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Interventions to reduce hospitalization and mortality for people with CKD should pay close attention to the management of associated comorbid conditions and cardiovascular disease in particular. (NG)
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Referral to specialists and models of care

REFERRAL TO SPECIALIST SERVICES

We recommend referral to specialist kidney care services for people with CKD in the following circumstances:
  • AKI or abrupt sustained fall in GFR
  • GFR o30 ml/min/1.73 m2 (GFR categories G4-G5)*
  • a consistent finding of significant albuminuria (ACR ≥300 mg/g [≥30 mg/mmol] or AER ≥300 mg/ 24 hours, approximately equivalent to PCR ≥500 mg/g [≥50 mg/mmol] or PER ≥500 mg/24 hours)
  • progression of CKD
  • urinary red cell casts, RBC <20 per high power field sustained and not readily explained
  • CKD and hypertension refractory to treatment with 4 or more antihypertensive agents
  • persistent abnormalities of serum potassium
  • recurrent or extensive nephrolithiasis
  • hereditary kidney disease.
(Level 1, B)
* If this is a stable isolated finding, formal referral (i.e., formal consultation and ongoing care management) may not be necessary and advice from specialist services may be all that is required to facilitate best care for the patients. This will be health-care system dependent.
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We recommend timely referral for planning renal replacement therapy (RRT) in people with progressive CKD in whom the risk of kidney failure within 1 year is 10–20% or higher,* as determined by validated risk prediction tools. (Level 1, B)
* The aim is to avoid late referral, defined here as referral to specialist services less than 1 year before start of RRT.
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CARE OF THE PATIENT WITH PROGRESSIVE CKD

We suggest that people with progressive CKD should be managed in a multidisciplinary care setting. (Level 2, B)
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The multidisciplinary team should include or have access to dietary counseling, education and counseling about different RRT modalities, transplant options, vascular access surgery, and ethical, psychological, and social care. (NG)
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TIMING THE INITIATION OF RRT

We suggest that dialysis be initiated when one or more of the following are present: symptoms or signs attributable to kidney failure (serositis, acid-base or electrolyte abnormalities, pruritus); inability to control volume status or blood pressure; a progressive deterioration in nutritional status refractory to dietary intervention; or cognitive impairment. This often but not invariably occurs in the GFR range between 5 and 10 ml/min/1.73 m2. (Level 2, B)
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Living donor preemptive renal transplantation in adults should be considered when the GFR is <20 ml/min/ 1.73 m2 , and there is evidence of progressive and irreversible CKD over the preceding 6–12 months. (NG)
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STRUCTURE AND PROCESS OF COMPREHENSIVE CONSERVATIVE MANAGEMENT

Conservative management should be an option in people who choose not to pursue RRT and this should be supported by a comprehensive management program. (NG)
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All CKD programs and care providers should be able to deliver advance care planning for people with a recognized need for end-of-life care, including those people undergoing conservative kidney care. (NG)
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Coordinated end-of-life care should be available to people and families through either primary care or specialist care as local circumstances dictate. (NG)
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The comprehensive conservative management program should include protocols for symptom and pain management, psychological care, spiritual care, and culturally sensitive care for the dying patient and their family (whether at home, in a hospice or a hospital setting), followed by the provision of culturally appropriate bereavement support. (NG)
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Recommendation Grading

Disclaimer

Overview

Title

Evaluation and Management of Chronic Kidney Disease

Authoring Organization

Endorsing Organization

Publication Month/Year

January 1, 2013

Supplemental Implementation Tools

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Male, Adolescent, Adult, Child, Infant, Older adult

Health Care Settings

Ambulatory, Hospital, Outpatient

Intended Users

Dietician nutritionist, nurse, nurse practitioner, physician, physician assistant

Scope

Counseling, Assessment and screening, Prevention, Management

Diseases/Conditions (MeSH)

D002318 - Cardiovascular Diseases, D007676 - Kidney Failure, Chronic, D007674 - Kidney Diseases

Keywords

chronic kidney disease, Albuminuria, Proteinuria

Source Citation

Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney inter., Suppl. 2013; 3: 1–150.

Supplemental Methodology Resources

Data Supplement, Evidence Tables

Methodology

Number of Source Documents
729
Literature Search Start Date
June 1, 2011
Literature Search End Date
November 1, 2012