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Chronic Kidney Disease: Diagnosis and Management - Adult - Ambulatory

Chronic Kidney Disease: Diagnosis and Management - Adult - Ambulatory - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Urology and Nephrology


Chronic Kidney Disease: Diagnosis and Management – Adult
Guideline Summary
Target Population: Adult patients with chronic kidney disease who are not on dialysis managed in ambulatory setting
Full Guideline: Chronic Kidney Disease: Diagnosis and Management - Adult - Ambulatory Clinical Practice Guideline
Chronic Kidney Disease Stages by GFR and Albuminuria categories
GFR categories Albuminuria categories
Stage Kidney function GFR (ml/min/1.73m
2
) Stage Albuminuria description Range
G1 Normal or high ≥ 90 A1 Normal to mildly increased < 30mg/g
G2 Mildly decreased 60-89 A2 Moderately increased 30-299 mg/g
G3a Mildly to moderately decreased 45-59 A3 Severely increased ≥300 mg/g
G3b Moderately to severely
decreased
30-44
G4 Severely decreased 15-29
G5 Kidney failure < 15
Recommendations to prevent CKD-related complications
Recommendations Targets
Blood Pressure Antihypertensive agent selection in CKD patients
Target BP ≤
140/90 mm Hg
For patients with
proteinuria
(i.e., urine
protein/Cr ratio
>0.5 or ≥0.22
African-Americans),
consider BP goal <
130/80 mm Hg
1
st

line
ACE inhibitor or ARB
Titrate to highest tolerable dose
2
nd
/3
rd

line
Diuretic/Calcium channel blocker*
* For patients with proteinuria, consider non-dihydropyridine calcium channel
blocker. For patients who are fluid overloaded, consider diuretic.
4
th
line Add alpha blocker or beta blocker
• If pt has proteinuria, avoid dihydropyridine calcium channel blockers without an ACE-I
or ARB, as can worsen proteinuria
Hyperlipidemia
• Statin therapy recommended with or without ezetimibe in patients ≥ 50 years and
patients 18-49 years with high cardiovascular risk
• DO NOT INITIATE statin therapy in dialysis patients.
Anti-platelet
therapy
• Daily low dose aspirin recommended for secondary prevention of CVD unless risk of
bleeding outweighs benefits
Glycemic Control Additional guidance can be found in
UW Health Diabetes clinical practice guideline
HbA1c ≤ 7 %
Metabolic
Acidosis
• If bicarbonate level < 22 mmol/L, prescribe sodium bicarbonate (650mg) 3 times daily
Initiation of ACE-I/ARB in CKD Patient
General Management If patient had change in K
+

If patient had change in serum
creatinine
• Check serum creatinine and
potassium 7-10 days after initiation
• If no increase in serum potassium or
creatinine, titrate drug according to
BP.
• Re-check renal function after 3
months and continue monitoring
depending on CKD stage (between
3-6 months)
K
+
≥ 6.1 Call Nephrology if established
w/service; if not, send pt to
ED/Urgent Care
Serum creatinine > 20% higher:
Reduce or withdraw drug
Recheck renal function after 1-2 weeks,
consider referral/consult to Nephrology
K
+
5.8-
6.1
Hold ACE-I/ARB;
Repeat K+ in 7-10 days
If serum creatinine higher by 5-19%,
recheck renal function after7-10 days.
If pt had creatinine >5%, recheck renal
function after each titration after starting
medication.
K
+
5-5.7 Advise pt to reduce K+ in diet;
repeat level in 7-10 days
Patient should be referred to Nephrology if:
• eGFR<30 mL/min/1.73m
2
• Persistent albuminuria (ACR >300 mg/g or
UACR ≥30mg/g)
1
• ≥ 20% decrease in eGFR
1
• Secondary hyperparathyroidism
1
• Suspected renal artery stenosis
• Persistent hyperkalemia/metabolic acidosis
1
• Recurrent kidney stones
14
• Unexplained hematuria
1
• Hereditary or unknown cause of CKD
1
• CKD and hypertension refractory to treatment with ≥ 3 agents
1
• Patient with Stage 4 CKD, regardless of cause, should be seen by nephrology as timely referral improves outcomes and costs.
• CKD patient should be seen by a nephrologist ≥ 12 months before starting dialysis to discuss vascular access with the patient.
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission.

Select drugs that may require monitoring/dose adjustment in CKD patients
Anti-hypertensives/
cardiac medications
• Beta blockers • Digoxin • Thiazides
Analgesics
• NSAIDS • Opioids • Tramadol
Antimicrobials
• Beta-lactams
• Fluoroquinolones
• Tetracyclines
• Anti-fungals
• Anti-virals
• Cephalosporins
• Macrolides
• Trimethoprim and
Trimethoprim/sulfamethoxazole
Lipid-lowering
• Statins • Fenofibrate
Anti-coagulants
• LMW heparins • Warfarin • Direct oral anticoagulants
Hypoglycemics
• Sulfonylureas • Insulin • Metformin
Gout-related
• Allopurinol • Colchicine
Miscellaneous
• Metoclopramide
• Lithium
• Gabapentin
• Ranitidine
• Bisphosphonates
Laboratory tests to evaluate CKD in patients upon diagnosis and for follow-up
Evaluation/Monitoring Frequency
Test/Intervention Rationale/
Indication
CKD 3a
(GFR 45-59)
CKD 3b
(GFR 30-44)
CKD 4
(GFR 15-29)
CKD 5
(GFR <15)
Basic metabolic panel Prognosis,
hyperkalemia, metabolic
bone disease
Per
Physician
discretion
Annually (unless
changes to
medication or
condition dictate
otherwise)
Every 3-4
months
Per Nephrologist
recommendation
Protein/creatinine ratio Prognosis
Urinalysis with Microscopy (UA) Prognosis
Hemoglobin/hematocrit Prognosis, anemia
Lipids CV risk stratification
Ultrasound of kidneys Prognosis
PTH, vitamin D*
*Test if GFR < 45 upon diagnosis
Metabolic bone disease
Phosphate**
**Test if GFR < 30 upon diagnosis
Metabolic bone disease
Suggested Patient Education and Renal Replacement Therapy Planning for CKD Patients
GFR
(ml/min/1.73m
2
)
Patient Education Renal Replacement Therapy Planning
G1
GFR ≥ 90
• Counsel patient on importance blood pressure
control, lipid management and glycemic control
(e.g., diabetes)
• Emphasize medication adherence (e.g.,
antihypertensives) to prevent disease progression
• Encourage lifestyle modifications to slow
progression of disease (e.g., physical activity,
smoking cessation)
• Counsel patient medications (OTC and
prescription) to be aware of Advise patient to limit
salt and eat less saturated and trans fats foods
Education is recommended to all patients with GFR <
60 and any patients with GFR > 60 and CKD due to
other factors (e.g., albuminuria.)
G2
GFR 60-89
G3a
GFR 45-59
G3b
GFR 30-44
• When GFR < 30 mL/min/1.73m2, in NON-dominant
arm, avoid blood pressure measurements, IVs and
blood draws
• Save veins/use hands for blood draws when possible
• If patient GFR < 30 mL/min/1.73m2 and patient has
never been evaluated by nephrology, consider
nephrology referral
G4
GFR 15-29
• Have shared decision making discussion/develop
renal replacement therapy plan, if needed
• Advise patient to register/attend for UW Health
Options Class
• Discuss whether patient is transplant candidate
• Consider advanced care planning discussion
• Consider palliative care discussion
• Consider transplant referral
• Think Peritoneal Dialysis first before hemodialysis
• Ensure timely placement of fistula (referral to vascular
surgery)
G5
GFR < 15
• Advanced Care Planning
• Palliative Care discussion
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission.