CKD

Rule out causes of acute deterioration

  • Obstruction
  • Nephrotoxics
  • Infection
  • BP
  • Diabetes

 

Data gathering

  • Red flags – weight loss
  • Others
    • tired, ankle swelling, SOB, itching, frequency, nocturia, medication changes
  • Examine
    • BP, weight, oedema, abdominal examination

 

Clinical management

  • Investigations
    • Bloods
      • FBC, U+Es, LFTs, calcium, phosphate, HbA1c, lipids
      • CKD 4 or 5 – bicarbonate, Vitamin D, PTH
    • Urine – dip, MSU, ACR
    • USS KUB
      • see below
  • Explanation
    • kidneys have several functions 1) filter blood, 2) maintain BP 3) help with red blood cell production. Over time, kidneys become less efficient, this is made worse by diabetes and high BP.
  • Treatment
    • Lifestyle – weight loss, exercise, stop smoking, reduce salt intake
    • Avoid nephrotoxic drugs
    • BP control
    • Vaccinations – annual flu, one off pneumococal
    • Statins
    • Aspirin – if QRISK > 20%
  • Follow-up / Safety-net
    • Annual blood tests, urine ACR, BP monitoring
    • Refer
      • stage 4 onwards
      • stage 3 with fall of eGFR >5ml/year
      • persistent proteinuria
      • macroscopic haematuria (if negative urological evaluation)
      • uncontrolled hypertension
      • Hb < 11 (after exclusion of other causes)
      • persistently abnormal potassium, calcium or phosphate
      • red flags (rapidly declining eGFR, hyperkalaemia, malignant hypertension, renal artery stenosis)

 

Urine ACR

  • ACR > 3.5 – microalbuminuria
  • ACR 30 – consider ACE-I/ARB
  • ACR 70 – consider ACE-I/ARB + referral
  • ACR > 250 – nephrotic range, consider urgent referral

nb: consider repeating and ensure first morning sample

nb: lower ranges if diabetic – see data intepretation ACR

USS KUB indications

  • progressive CKD (eGFR falls > 5 within 1 year or >10 within 5 years)
  • visible haematuria or persistent microscopic haematuria
  • urinary sepsis
  • FH of polycystic kidney disease
  • Stage 4 or 5 CKD

Vitamin D and calcium

  • Mineral metabolism is disturbed in most patients with CKD 4 onwards
  • If Vitamin D < 75 nmol/L – consider Adcal 2 tabs daily

BP targets

  • < 140/90 – non diabetic
  • <13/80 – diabetic