The level of evidence grades (A-D) are provided for the most significant recommendations and are defined at the end of the "Major Recommendations" field.
Screening and Diagnosis
All Adults at Increased Risk for Chronic Kidney Disease (CKD)
For patients at increased risk for CKD (e.g., diabetes, hypertension, family history of kidney failure, kidney stones, etc.) assess for markers of kidney damage:
- Measure blood pressure [A]
- Obtain estimated glomerular filtration rate (GFR)1 (serum creatinine levels should not be used as sole means to assess renal function)
- Protein-to-creatinine ratio or lbumin-to-creatinine ratio (first morning or random spot urine specimen)
- Urinalysis, fasting lipid profile, electrolytes, blood urea nitrogen (BUN)
Frequency
- Semi-annual blood pressure monitoring; more frequent monitoring if indicated
- Monitor GFR every 1–2 years
1If not calculated by lab, refer to the National Kidney Foundation website for GFR calculator (http://www.kidney.org/professionals/tools/)
Risk Factor Management and Patient Education
All Adults at Increased Risk for CKD
- Evaluation and management of comorbid conditions (e.g. diabetes, hypertension, urinary tract obstruction, cardiovascular disease)2
- Review medications for dose adjustment, drug interactions, adverse effects, therapeutic levels
- Educate on therapeutic lifestyle changes: dietary sodium intake < 2.4 grams/day (g/d) recommended for patients with CKD and hypertension [A], weight maintenance if body mass index (BMI) <25, weight loss if BMI ≥ 25, exercise and physical activity, moderation of alcohol intake, smoking cessation
Frequency. At each routine health exam
2Reference MQIC guidelines on diabetes, hypertension, hyperlipidemia and obesity (http://www.mqic.org).
Adults with CKD
All of the above plus:
- Develop clinical action plan for each patient, based on disease stage as defined by the National Kidney Foundation, Kidney Disease Outcomes Quality Initiative (K/DOQI) [B]
- Incorporate self-management behaviors into treatment plan at all stages of CKD [B]
Frequency. At each routine health exam
Core Principles of Treatment
Adults with CKD
- Stage 1 (GFR >90): Monitor GFR annually, smoking cessation, consider aspirin (ASA), consider angiotensin converting enzyme (ACE) and/or angiotensin receptor blocker (ARB) therapy, blood pressure (BP) goal <130/80, low density lipoprotein-cholesterol (LDL-C) goal <100
- Stage 2 (GFR 60–89): Nephrology referral if GFR decline > 4ml/min/yr, maintain BP and lipid goals as above
- Stage 3 (GFR 30–59): Consult Nephrologist and Renal Dietician; Suppress parathyroid hormone (PTH) with vitamin D to level appropriate for CKD stage; Phosphorus lowering treatment if > 4.6 mg/dl; Correct iron deficiency before start of epoetin therapy; Epoetin if hemoglobin (Hgb) (hematocrit [Hct]) <11 (33%); renal-specific vitamins; Update vaccines: hepatitis B virus (HBV), influenza, diphtheria/tetanus acellular pertussis vaccine (Tdap) and Pneumovax
- Stage 4 (GFR 15–29): Nephrology and vascular access surgery referrals, Epoetin if Hct <33%, Optimize Ca x P product to < 55 with specific agents, update vaccines as indicated, CKD education classes
- Stage 5 (GFR <15): Renal replacement therapy
Frequency. As indicated
Definitions:
Levels of Evidence for the Most Significant Recommendation
- Randomized controlled trials
- Controlled trials, no randomization
- Observational studies
- Opinion of expert panel
