Early detection

Risk

  • Age >60yo - test if \<50yo

  • DM

  • HTN

  • cardiovascular disease

  • smoking

  • obesity

  • family history of kidney disease

  • maori and PI

  • south asians

Investigations

If CKD: 1-2yrs

If DM or CKD: at least every 12mo

  • Serum Cr

    • repeat within 14d if abnormal

    • clinically signifiant if drop of 20% or greater

  • urine ACR - on first void

    • repeat 1-2 times over 3mo for confirmation

  • blood pressure

Normalbuniuria

ACR \<2.5M \<3.5F

Microalbuminuria

ACT 2.5-25M, 3.5-35F

Macroalbuminuia

ACR >25M, >35F

Management

CKD1 : egfr >90

CKD2: eGFR 60-89

kidney damage with mild decrease kidney function

persistent proteinuria/albuminuria

persistent haematuria/pyruia

redblood cell casts/dysmorphic cells

uss / other radiological abnormalities

investigation for those at increase risk - annualy

  • BP

  • assessment of proteinuria

  • urinalysis

  • weight

  • creatinine

  • K+

  • CVRA reduction

    • BP

    • lipids

    • gluocse

    • lifestyle

CKD 3a: 45-59

mild-moderate decrease kidney

  • as above +

  • monitor eFGR q3mo

  • avoid nephrotoxic drugs

  • prescribe antiproteinuric drugs if appropriate

  • adddress common complications

  • ensure drug dosages appropriate for level of kidney function

  • consider indications for referral to nephrologist

  • investigations: 3 monthly then six monthly if stabel

    • FBC

    • Iron stores

    • Ca/PO4

    • PTH (6 monthly)

    • ALP

CKD 3b: 30-44

moderate-severe decrease kidney funciton

  • as above + refer patients with DM to neprhology

CKD 4: 15-29

severe decrease kidney function

  • referral to nephrologist usually indicated

    • phsyical and psychosocial preparation for RRT

  • consider HepB vaccination expected to go onto dialysis

  • influenza

  • pneumococcus

  • investigations

    • plasma bicarbonate

CKD 5: \<15

endstage

  • refer

  • monthly blood schedule specified by renal unit

referal not necessary if:

  • stable eFGR ≥ 30

  • urine ACR \<30 (with no haematuria)

  • controlled blood pressure

Indications for referral

associated

  • reduced rates of progression to ES kidney disease

  • decreased need for and duration of hospitalisation

  • increase likelihood of permanent dialysis access created prior to dialysis onset

  • reduced inital costs of care following commencenemtn of dialysis

  • increase likelihood of kidney transplantation

  • decrease patient morbidity and mortalty

who

  • eGFR \<30

  • persistent ACR ≥30

  • consistent decline (>5mL over 6mon period on at least 3 separate) from baseline of \<60mL

  • Glomerular haematuria wiht macroalbuminuria (active sediment)

  • CKD and HTN hard to get to target despite ≥3 antihypertensives

  • DM with eGFR \<45

Treatment targets

Lifestyle

  • smoking

  • Weight

    • BMI ≤ 30

    • WC \<102M \<88cmF

    • sBP reduction 5-20mmHg per 10kg loss

  • physical activity

    • ≥30 mins mod. intensive PA (3-6 METS)

    • sBP reduction 4-9mmHg

  • Nutirtion

    • dietray salt ≤100mmol/day

    • 2-8mmhg reduction

  • EtOH

    • 2-4mmHg

Clincial

  • BP

    • ≤140/90

    • ≤130/80 if albuminuria or DM

    • ACEi or ARB

      • avoid combination

  • Proteinuria

    • >50% reduction of baseline

    • ACEi or ARB

  • Lipids

    • TC \<4

    • LDL \<2

    • HDL ≥ 1

    • TAG \<1.7

    • statins less effective with advanced CKD

  • Blood glucose

    • 4-6 fasting

    • HbA1c \<53

    • use metformin with caution if GFR 30-60

      • Avoid if GFR \<30