Identification of risk groups:
- testing for CKD should be offered if people have any of the following risk factors:
- diabetes
- hypertension
- cardiovascular disease (ischaemic heart disease, chronic heart failure, peripheral vascular disease and cerebral vascular disease)
- structural renal tract disease, renal calculi or prostatic hypertrophy
- multisystem diseases with potential kidney involvement - for example, systemic lupus erythematosus
- family history of stage 5 CKD or hereditary kidney disease
- incidental detection of haematuria or proteinuria
- do not use any of the following as risk factors indicating testing for CKD in adults, children and young people:
- age
- gender
- ethnicity
- obesity in the absence of metabolic syndrome, diabetes or hypertension.
- monitor adults, children and young people for the development or progression of CKD for at least 3 years after acute kidney injury (longer for people with acute kidney injury stage 3) even if eGFR has returned to baseline
- monitor GFR in people prescribed drugs known to be nephrotoxic such as calcineurin inhibitors and lithium. Check GFR at least annually in people receiving long-term systemic non-steroidal anti-inflammatory drug (NSAID) treatment
Testing for CKD: eGFR and albumin:creatinine ratio
- clinicians should use urine albumin:creatinine ratio (ACR) in preference to protein:creatinine ration (PCR) in order to detect proteinuria
- ACR has greater sensitivity than protein:creatinine ratio (PCR) for low levels of proteinuria. For quantification and monitoring of proteinuria, PCR can be used as an alternative. ACR is the recommended method for people with diabetes
- for the initial detection of proteinuria, if the ACR is between 3 mg/mmol and 70 mg/mmol, this should be confirmed by a subsequent early morning sample. If the initial ACR is 70 mg/mmol or more, a repeat sample need not be tested
- regard a confirmed ACR of 3 mg/mmol or more as clinically important proteinuria Quantify urinary albumin or urinary protein loss as in recommendation
- all people with diabetes, and people without diabetes with a GFR less than 60 ml/min/1.73 m^2, should have their urinary albumin/protein excretion quantified. The first abnormal result should be confirmed on an early morning sample (if not previously obtained)
- quantify by laboratory testing the urinary albumin/protein excretion of people with an eGFR 60 ml/min/1.73 m^2 or more if there is a strong suspicion of CKD
Frequency of monitoring - Frequency of monitoring of GFR (number of times per year, by GFR and ACR category) for people with, or at risk of, CKD
- use table below to guide the frequency of GFR monitoring (per year) for people with, or at risk of, CKD, but tailor it to the person according to:
- the underlying cause of CKD
- past patterns of eGFR and ACR (but be aware that CKD progression is often nonlinear)
- comorbidities, especially heart failure
- changes to their treatment (such as renin-angiotensin-aldosterone system [RAAS] antagonists, NSAIDs and diuretics)
- intercurrent illness whether they have chosen conservative management of CKD
GFR ( ml/min/1.73 m^2) and ACR categories and risk of adverse outcomes | | A1 < 3 mg/mol (normal to mildly increased) | A2 3 -30 mg/mol (moderately increased) | A3 > 30mg/mol (severely increased) |
| >= 90 ml/min/1.73 m^2 (Normal and High) | check eGFR <=1 time per year | check eGFR 1 time per year | check eGFR >=1 time per year |
| 60-89 ml/min/1.73 m^2 (Mild reduction related to normal range for young adult) | check eGFR <=1time per year | check eGFR 1 time per year | check eGFR >=1time per year |
| 45-59 ml/min/1.73 m^2 (mild-moderate reduction) | check eGFR 1time per year | check eGFR 1 time per year | check eGFR 2 times per year |
| 30-44 ml/min/1.73 m^2 (moderate-severe reduction) | check eGFR <=2 times per year | check eGFR 2 times per year | check eGFR >=2 times per year |
| 15-29 ml/min/1.73 m^2 (severe reduction) | check eGFR 2 times per year | check eGFR 2 times per year | check eGFR 3 times per year |
| < 15 ml/min/1.73 m^2 (kidney failure) | check eGFR 4 times per year | check eGFR >=4 times per year | check eGFR >=4 times per year |
ACR (albumin creatinine ratio) category | |
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Using the Table - some examples:
- CKD G3a A1 - CKD stage 3 A with an ACR less than 3 mg/mmol has a suggested requirement of x1 GFR measurement per year i.e. yearly monitoring
- CKD G3a A3 - CKD stage 3A with an ACR > 30mg/mmol has a suggested requirement of x2 GFR measurements per year i.e. 6 monthly monitoring
- CKD G5 A2- CKD stage 5 with an ACR between 3 and 30 mg/mmol has suggested requirement of >=4 GFR measurements per year
* Relative to young adult level
** Including nephrotic syndrome (ACR usually >220 mg/mmol)
Abbreviations: ACR, albumin:creatinine ratio; CKD, chronic kidney disease
Monitor people for the development or progression of CKD for at least 2-3 years after acute kidney injury, even if serum creatinine has returned to baseline
- where a highly accurate measure of GFR is required - for example, during monitoring of chemotherapy and in the evaluation of renal function in potential living donors - consider a gold standard measure (inulin, 51Cr-EDTA, 125I-iothalamate or iohexol)
- Defining progression
- define accelerated progression of CKD as:
- a sustained decrease in GFR of 25% or more and a change in GFR category within 12 months
- or a sustained decrease in GFR of 15 ml/min/1.73 m2 per year
- take the following steps to identify the rate of progression of CKD:
- obtain a minimum of 3 GFR estimations over a period of not less than 90 days
- in people with a new finding of reduced GFR, repeat the GFR within 2 weeks to exclude causes of acute deterioration of GFR- for example, acute kidney injury or starting renin-angiotensin system antagonist therapy
- be aware that people with CKD are at increased risk of progression to endstage kidney disease if they have either of the following:
- a sustained decrease in GFR of 25% or more over 12 months or
- a sustained decrease in GFR of 15 ml/min/1.73 m^2 or more over 12 months
Reference: