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    Identification of CKD: Algorithm A

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    rawan
    The document provides guidelines for identifying and managing chronic kidney disease (CKD) in adults. It outlines risk factors that warrant CKD testing and algorithms for estimating glomerular filtration rate (eGFR), diagnosing CKD, classifying its severity, and guiding treatment and referral decisions based on eGFR and albumin-to-creatinine ratio (ACR) levels.

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    Identification of CKD: Algorithm A

    Uploaded by

    rawan
    107 views3 pages
    The document provides guidelines for identifying and managing chronic kidney disease (CKD) in adults. It outlines risk factors that warrant CKD testing and algorithms for estimating glomerular filtration rate (eGFR), diagnosing CKD, classifying its severity, and guiding treatment and referral decisions based on eGFR and albumin-to-creatinine ratio (ACR) levels.

    Original Description:

    NICE Guidelines for CKD

    Original Title

    CKD NICE

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    The document provides guidelines for identifying and managing chronic kidney disease (CKD) in adults. It outlines risk factors that warrant CKD testing and algorithms for estimating glomerular filtration rate (eGFR), diagnosing CKD, classifying its severity, and guiding treatment and referral decisions based on eGFR and albumin-to-creatinine ratio (ACR) levels.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    107 views3 pages

    Identification of CKD: Algorithm A

    Uploaded by

    rawan
    The document provides guidelines for identifying and managing chronic kidney disease (CKD) in adults. It outlines risk factors that warrant CKD testing and algorithms for estimating glomerular filtration rate (eGFR), diagnosing CKD, classifying its severity, and guiding treatment and referral decisions based on eGFR and albumin-to-creatinine ratio (ACR) levels.

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    Identification of CKD

    Offer testing for CKD using eGFRcreatinine and ACR to people with any of the following risk factors:
    diabetes
    hypertension
    acute kidney injury
    cardiovascular disease (ischaemic heart disease, chronic heart failure, peripheral vascular disease or
    cerebral vascular disease)
    structural renal tract disease, recurrent renal calculi or prostatic hypertrophy
    multisystem diseases with potential kidney involvement - for example, systemic lupus erythematosus
    family history of end-stage kidney disease (GFR category G5) or hereditary kidney disease
    opportunistic detection of haematuria.

    Algorithm A

    Monitor eGFR at least annually in people prescribed drugs known to be nephrotoxic.


    (see 1.127 and 1.1.28)

    Estimate GFR using serum creatinine


    (using the CKD-EPI creatinine equation [see 1.1.2])
    AND
    Test for proteinuria using ACR, ideally on early morning sample
    Opportunistic/ incidental
    detection of reduced GFR
    or proteinuria.

    To manage isolated
    invisible haematuria,
    follow recommendations
    1.124 to 1.126.

    Carry out a dipstick


    urinalysis where ACR 3
    mg/mol and haematuria
    status unknown

    For a new finding of eGFR<60 ml/min/1.73 m2 repeat eGFR


    within 2 weeks to exclude AKI (see 1.1.13)

    No AKI

    Where eGFR <60 ml/min/1.73 m2 and ACR 3 mg/mol


    repeat the abnormal test (using an early morning urine
    where the initial ACR was 3-70 mg/mol) after 3 months to
    determine if the abnormality is persistent

    Where ACR is abnormal

    If ACR 3mg/mol
    in repeat tests

    AKI

    Follow NICE guidance on


    acute kidney injury (NICE
    clinical guideline 169)

    Where GFR is abnormal

    If eGFR <45ml/min/1.73 m2
    in repeat tests
    If eGFR is persistently
    45-59 ml/min/1.73 m2 for 90 days and ACR
    <3mg/mol, consider using
    eGFRcystatin C
    (CKD-EPIcys)
    (see 1.1.14)

    Confirmed by CKDEPI cystatin C


    (eGFRcysC <60ml/
    min/1.73 m2)

    Diagnose CKD
    Classify according to algorithm B
    (see 1.2.1)

    If eGFR 60 ml/min/1.73 m2
    and/or ACR <3 mg/mol in repeat
    tests

    Not confirmed by
    CKD-EPI cystatin C
    (eGFRcysC 60ml/
    min/1.73 m2)

    Do not diagnose CKD


    If risk factors for CKD are present, repeat testing at a
    frequency (annual) tailored to the individual
    (see 1.3.1 and 1.3.2)

    Abbreviations: ACR = albumin creatinine ratio; AKI = acute kidney injury; CKD = chronic kidney disease; CKD-EPI= chronic kidney
    disease epidemiology collaboration); eGFR = estimated glomerular filtration rate; G5=eGFR<15ml/min/1.73m2

    Chronic Kidney disease: early identification and management of chronic kidney disease in adults in primary and
    secondary care NICE clinical guideline 182 (July 2014).
    National Institute for Health and Care Excellence 2014. All rights reserved.

    Classification and referral for specialist assessment

    Algorithm B

    A1
    Normal to mildly increased
    <3

    GFR categories (ml/min/1.73m2)


    Description and range

    G1

    Normal and high

    Mild reduction
    related to normal
    range for a young
    adult
    Mildmoderate
    reduction

    6089

    G3b

    Moderatesevere
    reduction

    3044

    G4

    Severe reduction

    1529

    G5

    Kidney failure

    <15

    G3a

    4559

    A3
    Severely increased
    >30

    Manage in primary care according to recommendations (see


    algorithm C)

    90

    No CKD in the absence of


    markers of kidney damage
    G2

    ACR categories (mg/mmol)


    Description and range
    A2
    Moderately increased
    330

    Refer for specialist assessment if


    the person has:
    - a sustained decrease in GFR of
    25% or more and a change in GFR
    category or sustained decrease in
    GFR of 15 ml/min/1.73 m2 or
    more within 12 months
    - hypertension that remains poorly
    controlled despite the use of at
    least 4 antihypertensive drugs at
    therapeutic doses (see also
    Hypertension NICE clinical
    guideline 127)
    - known or suspected rare or
    genetic causes of CKD
    - suspected renal artery stenosis

    Refer for specialist assessment if


    the person has any of the criteria
    in A2, or:
    - ACR 70 mg/mmol or more, unless
    known to be caused by diabetes
    and already appropriately treated
    - haematuria

    Refer for specialist assessment

    For guidance on frequency of GFR monitoring, see recommendation 1.3.2 in the NICE guideline. For guidance on referral, see also recommendations 1.5.1 to 1.5.5
    Abbreviations: ACR, albumin creatinine ratio; CKD, chronic kidney disease; GFR, glomerular filtration rate.
    Chronic Kidney disease: early identification and management of chronic kidney disease in adults in primary and secondary care NICE clinical guideline 182 (July 2014).
    National Institute for Health and Care Excellence 2014. All rights reserved.

    Algorithm C
    Classification and referral for specialist assessment
    GFR 60

    GFR category (ml/min/1.73m 2)


    GFR 4559
    GFR 3044

    GFR 1529

    GFR <15

    Identify and delay progression (see section 1.1 of the NICE guideline)
    Identify those at risk of progression (presence of cardiovascular disease; proteinuria; acute kidney injury, hypertension; diabetes; smoking; African-Caribbean or Asian family origin; chronic use of NSAIDs; untreated urinary outflow tract
    obstruction) and work with them to optimise their health (recommendation 1.3.7 in the NICE guideline)
    Assess risk of adverse outcomes using GFR and ACR category
    Offer a low-cost reninangiotensinaldosterone system antagonist (see recommendation 1.6.3 in the NICE guideline) to people with CKD and:

    diabetes and an ACR of 3 mg/mmol or more (ACR category A2 or A3)

    hypertension and an ACR of 30 mg/mmol or more (ACR category A3)

    an ACR of 70 mg/mmol or more (irrespective of hypertension or cardiovascular disease).


    Control blood pressure (see recommendations 1.6.1 and 1.6.2 in the NICE guideline) to targets of:

    120139/<90 mmHg in people without diabetes with ACR < 70 mg/mmol

    120129/<80 mmHg in people with diabetes or with ACR 70 mg/mmol


    Modify comorbidities (see sections 1.3 and 1.4 of the NICE guideline)
    Reduce risk of cardiovascular disease (control blood pressure; use antiplatelet therapy where indicated) (see recommendations 1.6.3, 1.6.5 and 1.6.16)
    Follow the recommendations in Lipid modification (NICE clinical guideline 181) for the use of statins in CKD
    Manage diabetes according to Type 1 diabetes and Type 2 diabetes (NICE clinical guidelines 15 and 87)
    Encourage people to exercise, achieve a healthy weight and stop smoking (recommendation 1.4.6)
    Prevent and treat osteoporosis (recommendation 1.7.3) in people with CKD (offer bisphosphonates if indicated in people with a GFR of 30 ml/min/1.73 m2 or more [GFR category G1, G2 or G3])
    If vitamin D supplementation is indicated (recommendation 1.7.5 and 1.7.6) in people with CKD:

    offer colecalciferol or ergocalciferol to people who also have vitamin D deficiency

    offer alfacalcidol (1-hydroxycholecalciferol) or calcitriol (1-25-dihydroxycholecalciferol) to people with GFR <30 ml/min/1.73m 2 if vitamin D deficiency has been corrected and symptoms of CKDmineral and bone disorders persist
    Education and information
    Offer education and information (see recommendation 1.4.2 of the NICE guideline) to enable people with CKD to understand:

    What CKD is and how it can affect them

    What questions they should ask about their kidneys

    The advantages and disadvantages of the treatments that are available

    How they can manage their own condition

    The social and financial impact of CKD and the benefits/allowances available

    How to adjust psychologically to a diagnosis of CKD and where to find help


    Ensure systems are in place to enable people to share in decision-making about their care, and support self-management (recommendation
    1.4.10)
    Prevent uraemic complications (see recommendation 1.7.8 of NICE guideline)
    Check haemoglobin in people with GFR <45 ml/min/1.73m2 to identify anaemia
    Consider oral sodium bicarbonate supplementation for people with both a GFR <30 ml/min/1.73m2 and a serum bicarbonate
    concentration of <20 mmol/litre
    Measure serum calcium, phosphate and parathyroid hormone concentrations in people with a GFR <30 ml/min/1.73m2
    (recommendation 1.7.2)
    Education about treatment options for category G5 CKD and preparation for
    renal replacement therapy (see section 1.4 of the NICE guideline)
    Explain to people the importance of:
    Informed choice
    Creating a fistula or inserting a peritoneal catheter
    Timely renal replacement treatment (recommendation 1.4.2)
    Conservative management and when it may be considered

    Abbreviations: ACR, albumin creatinine ratio; CKD, chronic kidney disease; GFR, glomerular filtration rate.
    Chronic Kidney disease: early identification and management of chronic kidney disease in adults in primary and secondary care NICE clinical guideline 182 (July 2014).
    National Institute for Health and Care Excellence 2014. All rights reserved.

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