Evaluation and Management of Chronic Kidney Disease
Definition and classification of CKD
DEFINITION OF CKD
STAGING OF CKD
|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|
|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
EVALUATION OF CKD
Evaluation of chronicity
- 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.
Evaluation of cause
Evaluation of GFR
- 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.
- 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.
- 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).
- 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.’’
- 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.
- 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.
- 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.
- We recommend reporting serum cystatin C concentration rounded to the nearest 100th of a whole number when expressed as conventional units (mg/l).
- 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.’’
Evaluation of albuminuria
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.
- 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.
Definition, identification, and prediction of CKD progression
DEFINITION AND IDENTIFICATION OF CKD PROGRESSION
- 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.
PREDICTORS OF PROGRESSION
Management of progression and complications of CKD
PREVENTION OF CKD PROGRESSION
BP and RAAS interruption
CKD and risk of AKI
- with diabetes
- without diabetes and GFR <30 ml/min/ 1.73 m2 (GFR categories G4-G5),
Additional dietary advice
COMPLICATIONS ASSOCIATED WITH LOSS OF KIDNEY FUNCTION
Definition and identification of anemia in CKD
Evaluation of anemia in people with CKD
- 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).
CKD METABOLIC BONE DISEASE INCLUDING LABORATORY ABNORMALITIES
Vitamin D supplementation and bisphosphonates in people with CKD
Other complications of CKD: CVD, medication dosage, patient safety, infections, hospitalizations, and caveats for investigating complications of CKD
CKD AND CVD
CAVEATS WHEN INTERPRETING TESTS FOR CVD IN PEOPLE WITH CKD
CKD AND PERIPHERAL ARTERIAL DISEASE
MEDICATION MANAGEMENT AND PATIENT SAFETY IN CKD
- Avoidance of high osmolar agents
- Use of lowest possible radiocontrast dose
- Withdrawal of potentially nephrotoxic agents before and after the procedure
- Adequate hydration with saline before, during, and after the procedure
- Measurement of GFR 48–96 hours after the procedure
Gadolinium-based contrast media
CKD AND RISKS FOR INFECTIONS, AKI, HOSPITALIZATIONS, AND MORTALITY
CKD and risk of infections
CKD and risk of AKI
CKD and risk of hospitalization and mortality
Referral to specialists and models of care
REFERRAL TO SPECIALIST SERVICES
- 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.
CARE OF THE PATIENT WITH PROGRESSIVE CKD
TIMING THE INITIATION OF RRT
STRUCTURE AND PROCESS OF COMPREHENSIVE CONSERVATIVE MANAGEMENT
Evaluation and Management of Chronic Kidney Disease
January 1, 2013
External Publication Status
Country of Publication
Female, Male, Adolescent, Adult, Child, Infant, Older adult
Health Care Settings
Ambulatory, Hospital, Outpatient
Counseling, Assessment and screening, Prevention, Management
D002318 - Cardiovascular Diseases, D007676 - Kidney Failure, Chronic, D007674 - Kidney Diseases
chronic kidney disease, Albuminuria, Proteinuria
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.