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Early identification of CKD in primary care

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

Authoring team

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)

G1

>= 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

G2

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

G3a

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

G3b

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

G4

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

G5

< 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

ACR (mg/mmol)

A1

<3

A2

3-30*

A3

>30**

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:


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