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Early Identification and Management of Chronic Kidney Disease in Adults

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Early Identification and Management of Chronic Kidney Disease in Adults EDUCATION PRACTICE GUIDELINES Early identification and management of chronic kidney disease in adults: summary of updated NICE guidance Serena Carville,1 David Wonderling,1 Paul Stevens,2 on behalf of the Guideline Development Group 1National Clinical Guideline Centre, The publication of an internationally accepted definition other abnormalities caused by tubular disorders, abnor- Royal College of Physicians, London and classification of chronic kidney disease (CKD) 12 years malities detected by histology, structural abnormalities NW1 4LE, UK ago precipitated a proliferation of research and literature detected by imaging, and previous kidney transplanta- 2East Kent Hospitals University NHS Foundation Trust, Canterbury surrounding the identification of CKD, risk factors for pro- tion. Cystatin C is an alternative endogenous filtration CT1 3NG, UK gression, and important prognostic factors.1 It also stimu- marker that can be used to estimate glomerular filtration Correspondence to: P Stevens lated continuing debate concerning the criteria used for rate. In people with GFR above 45 mL/min/1.73 m2, GFR [email protected] definition of CKD and exactly how ageing influences CKD estimates based on cystatin C are more powerful predic- Cite this as: BMJ 2014;349:g4507 2 3 doi: 10.1136/bmj.g4507 and its sequelae. The National Institute for Health and tors of clinical outcomes than is creatinine based esti- Care Excellence (NICE) has modified its previous recommen- mated GFR, especially in people with no proteinuria.7 8 This is one of a series of BMJ dations on the classification of CKD,4 partly based on Kidney • Do not diagnose CKD in people with: summaries of new guidelines 5 based on the best available Disease Improving Global Outcomes (KDIGO) and driven – An estimated GFRcreatinine of 45-59 mL/min/ 2 evidence; they highlight important by prognostic data from large observational studies. NICE 1.73 m and recommendations for clinical has also recognised a requirement for better identification of – An estimated GFRcystatinC of more than practice, especially where 2 uncertainty or controversy exists. people at risk of adverse outcome and covers some key areas 60 mL/min/1.73 m and Further information about the relating to the management of CKD, including frequency of – No other marker of kidney disease. (New guidance and the supporting monitoring, progression of CKD, acute kidney injury, and recommendation.) evidence statements are in the full renin-angiotensin system blockade. This article summarises • To detect and identify proteinuria, use urine version on thebmj.com the most recent recommendations from NICE.6 albumin:creatinine ratio in preference to protein:creatinine ratio, because it has greater Recommendations sensitivity for low levels of proteinuria. For NICE recommendations are based on systematic reviews of quantification and monitoring of high levels of thebmj.com best available evidence and explicit consideration of cost proteinuria (albumin:creatinine ratio ≥70 mg/mmol), Previous articles in this effectiveness. When minimal evidence is available, rec- protein:creatinine ratio can be used as an alternative. series ommendations are based on the Guideline Development Albumin:creatinine ratio is the recommended Group’s experience and opinion of what constitutes good method for people with diabetes. (Updated Ж Lipid modification practice. Evidence levels for the recommendations are in recommendation.) and cardiovascular the full version of this article on thebmj.com. • Offer testing for CKD using estimated GFRcreatinine risk assessment and albumin:creatinine ratio to people with any of for the primary and Investigations for chronic kidney disease the following risk factors: secondary prevention of • Clinical laboratories should: – Diabetes cardiovascular disease: – Use the Chronic Kidney Disease Epidemiology – Hypertension summary of updated Collaboration (CKD-EPI) creatinine equation to – Acute kidney injury NICE guidance estimate GFRcreatinine, using creatinine assays – Cardiovascular disease (ischaemic heart disease, (BMJ 2014;349:g4356) with calibration traceable to standardised reference chronic heart failure, peripheral vascular disease, Ж The management material or cerebral vascular disease) of atrial fibrillation: – Use creatinine assays that are specific (for example, – Structural renal tract disease, renal calculi, or summary of updated enzymatic assays) and zero biased compared with prostatic hypertrophy NICE guidance isotope dilution mass spectrometry and – Multisystem diseases with potential kidney (BMJ 2014;348:g3655) – Participate in a UK national external quality involvement—for example, systemic lupus Ж Prevention and assessment scheme for creatinine. (New erythematosus management of pressure recommendation.) – Family history of end stage kidney disease (GFR Consider using eGFRcystatinC at initial diagnosis to category G5) or hereditary kidney disease ulcers: summary of NICE • confirm or rule out CKD in people with: – Opportunistic detection of haematuria. (Updated guidance – An estimated GFRcreatinine of 45-59 mL/min/ recommendation.) (BMJ 2014;348:g2592) 1.73 m2, sustained for at least 90 days and Ж Management – No proteinuria (albumin:creatinine ratio <3 mg/ Classification of chronic kidney disease of psychosis and mmol) or other marker of kidney disease. (New • Classify CKD by using a combination of GFR and schizophrenia in adults recommendation.) albumin:creatinine ratio (ACR) categories (as (BMJ 2014;348:g1173) Markers of kidney disease include albuminuria illustrated in figure 1). Be aware that: Ж Early management of (albumin:creatinine ratio >3 mg/mmol), urine sediment – Increased albumin:creatinine ratio is associated head injury: summary of abnormalities (haematuria, red blood cell casts, white with increased risk of adverse outcomes updated NICE guidance blood cell casts, oval fat bodies or fatty casts, granular – Decreased GFR is associated with increased risk of (BMJ 2014;348:g104) casts, and renal tubular epithelial cells), electrolyte and adverse outcomes PB 2 August 2014 | the bmj the bmj | 2 August 2014 29 EDUCATION PRACTICE – Increased albumin:creatinine ratio and decreased Indications for referral GFR in combination multiply the risk of adverse • People with CKD in the following groups should outcomes. (New recommendation.) normally be referred for specialist assessment: An incidental finding of clinically important proteinu- – GFR less than 30 mL/min/1.73 m2 (GFR category ria should always be considered in the context of GFR G4 or G5), with or without diabetes* c ategory. – Albumin:creatinine ratio 70 mg/mmol or more, unless known to be caused by diabetes and already Indications for renal ultrasound appropriately treated • Offer a renal ultrasound scan to all people with CKD who: – Albumin:creatinine ratio 30 mg/mmol (category – Have accelerated progression of CKD (see A3) or more, together with haematuria “Defining progression of CKD”) – Sustained decrease in GFR of 25% or more and – Have visible or persistent invisible haematuria a change in GFR category or sustained decrease – Have symptoms of urinary tract obstruction in GFR of 15 mL/min/1.73 m2 or more within – Have a family history of polycystic kidney disease 12 months and are aged over 20 years – Hypertension that remains poorly controlled – Have a GFR of less than 30 mL/min/1.73 m2 (GFR despite the use of at least four antihypertensive category G4 or G5) drugs at therapeutic doses (see also NICE clinical – Are considered by a nephrologist to require a renal guideline 127 on hypertension (www.nice.org.uk/ biopsy. (Updated recommendation.) Guidance/CG127)) – Known or suspected rare or genetic causes of CKD Frequency of monitoring – Suspected renal artery stenosis. (Updated • Use figure 2 to guide the frequency of GFR monitoring recommendation.) for people with or at risk of CKD, but tailor it to the *Where this is a stable isolated finding, formal referral may not be person according to: indicated and advice may be all that is required. The aim is to avoid The underlying cause of CKD late referral of those people likely to progress to requirement for renal – replacement therapy within one year. – Past patterns of estimated GFR and albumin:creatinine ratio (but be aware that • People with CKD and renal outflow obstruction progression of CKD is often non-linear) should normally be referred to urological services, – Comorbidities, especially heart failure unless urgent medical intervention is required—for – Changes to their treatment (such as renin- example, for the treatment of hyperkalaemia, severe angiotensin-aldosterone system antagonists, non- uraemia, acidosis, or fluid overload. steroidal anti-inflammatory drugs, and diuretics) – Intercurrent illness Pharmacotherapy – Whether they have chosen conservative Choice of antihypertensive agent and blood pressure control management of CKD. (New recommendation.) • Offer a low cost renin-angiotensin system antagonist • Monitor people for the development or progression of to people with CKD and: CKD for at least two to three years after acute kidney – Diabetes and an albumin:creatinine ratio of injury, even if serum creatinine has returned to 3 mg/mmol or more (category A2 or A3) baseline. (New recommendation.) – Hypertension and an albumin:creatinine ratio of 30 mg/mmol or more (category A3) Defining progression of CKD – An albumin:creatinine ratio of 70 mg/mmol • Define accelerated progression of CKD as: or more (irrespective of hypertension or – A sustained decrease in GFR of 25% or
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