camden chronic kidney disease pathway 2 ckd 3a ckd 3b ckd
TRANSCRIPT
Camden Chronic Kidney Disease Pathway
Renal Function (eGFR) should be measured
annually in all patients with
Diabetes, Hypertension, Cardiovascular
Disease and Heart Failure
Other groups at risk:
Afro-Caribbean & South Asian populations
Structural renal tract disease, kidney stones or
prostatic hypertrophy
Multisystem diseases with potential kidney
involvement eg SLE
Family history or hereditary kidney disease
Patients on long term nephrotoxic drug eg
Lithium, NSAIDS
Management in Primary Care
Treat modifiable risk factors
Lifestyle advice
Smoking, weight, exercise, salt &
alcohol intake
Stop nephrotoxic drugs
Blood Pressure Control
Influenza & Pneumococcus
immunisation
Assess Cardiovascular Risk
Consider Statin, Aspirin
V2.2 Links updated Feb 16Pathway created by Alex Warner July 2012 Reviewed by Alex Warner Sept 2015Review due Sept 2018
eGFR > 60 CKD 1 or
2
eGFR >60 normal unless
evidence of kidney disease
(structural abnormality and/or proteinuria and/or
proteinuria + haematuria)
Blood Pressure control
Monitor BP at least annually
Target < 140/90 (non-diabetics)
or < 130/80 (urine PCR >100 or diabetic )
If urine ACR >30 or PCR >50 or if diabetic with
microalbuminuria: ACEI or ARB first line
(avoid if K+ >5 mmol/L)
Check Creatinine, K+: Before start, after 2 weeks &
after each dose change
If Creatinine increases by >30% or GFR falls by
>25%, Repeat with K+ and seek advice
Renal Ultrasound for:
Progressive CKD
(eGFR falls > 5 within 1 yr
or > 10 within 5 yrs)
Visible or persistent invisible haematuria
Urinary sepsis, Lower Urinary Tract Symptoms
Family history of polycystic kidney disease
(Aged over 20)
Stage 4 or 5 CKD
Hyperkalaemia
If K+ > 6 mmol/L
Check no haemolysis
Check diet (Bananas,
soft fruit, fruit juice,
chocolate)
Stop NSAIDs and
LoSalt, Stop K+
retaining diuretics
Stop ACEI/ARB if
hyperkalaemia persists
+ Potassium, Calcium , Phosphate
Blood Pressure, Creatinine and eGFR, Hb, Urine Protein Creatinine Ratio (PCR)
Urgent referral
Acute Kidney Injury
(Acute renal failure)
Malignant hypertension
Hyperkalaemia
(K+ > 7 mmol/L)
Nephrotic syndrome
eGFR 45 – 59 eGFR 30 - 44
CKD 3A CKD 3B
Moderate decrease in GFR, with or without
other evidence of kidney damage
If new, confirm with repeat within 2 weeks
eGFR 15 – 29
CKD 4
Severe decrease in
GFR +/- other evidence
of kidney damage
eGFR <15
CKD 5
Established renal
failure
+ Bicarbonate, Vitamin D, PTH
Persistent
proteinuria >1+
Check spot urine for
ACR (or PCR)
ACR >3.5 / PCR >15
Microalbuminuria
ACR 30 / PCR 50
If hypertensive
consider ACEi/ARB
ACR 70 / PCR 100
BP control - ACEi/ARB
Refer
ACR >250 / PCR >300
Nephrotic range
Urgent ReferralAcute Kidney Injury
eGFR is unreliable in AKI so
review of sudden deterioration in
serum creatinine should be used to
identify AKI
Review all previous results to
determine rate of decline
Refer RFH
renal unit
AKI phone
07908422116
Repeat
within 5 days
Refer acute
medicine
Reasons for Referral
CKD 4 & 5
Referral or discussion advised even if dialysis may
not be appropriate in conjunction with secondary
care. Discuss prior to referral where elderly/frail/
terminal illness & stable CKD/BP/Hb.
Isolated proteinuria / PCR > 100
Or PCR >45 and microscopic haematuria
Macroscopic haematuria
(after negative urological evaluation)
Progressive fall in eGFR
(>15 mL/min over 12 months)
Fall of eGFR of 25% during first 2 months on
ACEI / ARB
Uncontrolled Hypertension
(BP > 150/90 on 3 agents)
Anaemia (after exclusion of other causes)
Where Hb ≤ 11 or if symptomatic
Persistently abnormal serum K+, Ca2+, PO4
Suspected renal artery stenosis, rare or genetic
causes or underlying systemic illness,
e.g. SLE, vasculitis, myeloma
Every 12 months 6 monthly 3 monthly
Creat >2x baseline
Creat >3x baseline
Creat >1.5x baseline
Check eGFR
Other
Investigations
Test Urine
Management
Cardiovascular Risk
CKD is a powerful risk factor for
cardiovascular disease
Statins: Secondary prevention: all
with established vascular disease:
MI, angina, stroke, Heart Failure due
to CHD, diabetics >40 yrs. Primary
prevention: if 10yr CVD risk >20%
Aspirin: Secondary prevention: All
with established vascular disease ,
Primary prevention: Consider if 10yr
CVD risk >20%
Mineral metabolism
is disturbed in most
patients with CKD4/5:
25 OH Vit D:
If less than 75 nmol/l
Calceos / Adcal D3 2 tabs
daily or cholecalciferol
20,000 iu weekly
ReferencesThis pathway based on the North Central London CKD Guide 2011DOH 2005 - RCP National Collaborating Centre for Chronic Conditions -The Renal Association -Clinical contact for this pathway: Dr John ConnollyComments & enquires relating to medication: NHS Camden Medicines Management Team Refer to current BNF or SPC for full medicines information
[email protected] CKD Guidelines
CKD Guidance
NSF for renal disease
Information needed on referral
General medical history
Urinary symptoms
Medication (dates of starting and
stopping ACEI/ARB if applicable)
Examination e.g. BP, oedema,
bladder
Urine dipstick for blood and protein
Urine culture and PCR
(if protein present)
FBC, Creatinine & eGFR, Urea, Na+,
K+, Albumin, Calcium, Phosphate,
Cholesterol, HbA1c (in diabetes)
List all old Creatinine results (as well
as any eGFR reports) with dates
Result of renal ultrasound if available.
CICS Referral