Home > BNSSG ICB > Development Area >

Chronic Kidney Disease (DRAFT)

Checked: not set yet by Vicky Ryan Next Review: not set yet

Overview

Diagnosis

Chronic kidney disease (CKD) is an abnormality of kidney function, or structure, that is present for more than 3 months, with implications for health. This includes all people with an eGFR of less than 60 ml/min/1.73m² on at least 2 occasions 90 days apart (with or without markers of kidney damage), as well as those with eGFR>60ml/min/1.73m² who have other markers of kidney damage.

The main markers of kidney disease to consider are albuminuria (ACR >3 mg/mmol) and/or haematuria (of presumed or confirmed renal origin). Others include electrolyte abnormalities due to tubular disorders, renal histological abnormalities, structural abnormalities detected by imaging (e.g. polycystic kidneys, reflux nephropathy) or a history of kidney transplantation.

Risks of Chronic Kidney Disease

People with CKD are twenty times more likely to die of cardiovascular disease than to develop kidney failure or require renal replacement therapy (RRT- dialysis or transplantation). The aim of early identification and treatment of CKD is to reduce the risk of cardiovascular disease, as well as the risk of progression to kidney failure. Risk can be stratified by GFR and ACR categories as shown below. Patients in the highest ACR category can be at high risk even if their eGFR is currently preserved.

GFR and ACR categories with risk of adverse outcomes, and recommended monitoring frequency in adults with CKD

ACR category A1: normal to mildly increased

(<3 mg/mmol)

ACR category A2: moderately increased

(3 to 30 mg/mmol)

ACR category A3: severely increased

(>30 mg/mmol)

GFR category G1:

(90 ml/min/1.73m²)

Normal and high

Low risk (not CKD if no other markers of kidney damage)

0-1 times per year

Moderate risk

Once per year

High risk

1 or more times per year

GFR category G2:

(60- 89 ml/min/1.73m²)

Mild reduction related to normal range for a young adult

Low risk (not CKD if there are no other markers of kidney damage)

0-1 times per year

Moderate risk

Once per year

High risk

1 or more times per year

GFR category G3a:

(45-59 ml/min/1.73m²)

Mild to moderate reduction

Moderate risk

Once per year

High risk

Once per year

Very high risk

Twice per year

GFR category G3b:

(30-44 ml/min/1.73m²)

Moderate-severe reduction

High risk

1-2 times per year

Very high risk

Twice per year

Very high risk

Twice per year

GFR category G4:

(15-29 ml/min/1.73m²)

Severe reduction

Very high risk

Twice per year

Very high risk

Twice per year

Very high risk

Three times yearly

GFR category G5:

(<15 ml/min/1.73m²)

Kidney failure

Very high risk

Four times yearly

Very high risk

Four or more times yearly

Very high risk

Four or more times yearly

Management in primary care

Once CKD is identified, management should include:

Monitoring – at a frequency indicated by overall risk (see table above)
Management with drugs which reduce albuminuria (ACE inhibitors, ARBs, SGLT2 inhibitors, finerenone) and therefore slow progression of CKD
Reduction of cardiovascular risk through lipid modification and tight blood pressure control.

Recommended management is summarised in the NBT renal service flowchart for CKD management and in CKS guidelines for Chronic Kidney Disease

CKD is a chronic disease and requires regular review. EMIS templates can help guide management and assess risk.

Risk assessment in primary care

The Kidney Failure Risk Equation is a tool that should be used to assess risk or progression to renal replacement therapy and guide referral (see section below).

Use of SGLT-2 Inhibitors in CKD

SGLT-2 inhibitors are now recommended by NICE for most patients with CKD and T2DM(3, 4), but also for patients with CKD who do not have diabetes but have significant albuminuria. After initiation of SGLT2 inhibitors, renal function usually declines slightly, but resolves within 1-3 months. No specific renal monitoring required before 3 months. If eGFR drops <30ml/min/1.73m2 or >25% from baseline during treatment, do not stop treatment without discussion with heart failure & renal specialist (consider Renal advice & guidance).

Finerenone

Finerenone is a mineralocorticoid receptor antagonist (similar to spironolactone) which is recommended by NICE to treat CKD in people with T2DM and albuminuria, after establishment of ACE inhibitor/ARB treatment and SGLT2i treatment.(5)

Please see the BNSSG formulary for a link to guidelines on when these drugs should be considered for use in primary care.

(3) Overview | Dapagliflozin for treating chronic kidney disease | Guidance | NICE

(4) NICE | Empagliflozin for treating chronic kidney disease

(5) NICE | Finerenone for treating chronic kidney disease in type 2 diabetes

Who to Refer

Please note that if you are unsure about the need for referral, the NBT Renal team provides a consultant led Advice & Guidance service for non-urgent queries.

Referral Criteria

Unless red flag features are present (see below) or referral deemed inappropriate due to patients wishes or comorbidities, adults with CKD should be referred for specialist assessment if they meet any of the following criteria:

a 5-year risk of needing renal replacement therapy of greater than 5% (measured using the 4-variable Kidney Failure Risk Equation)*
a urine albumin:creatinine ratio (ACR) of 70 mg/mmol or more, unless known to be caused by diabetes and already appropriately treated
an ACR of more than 30 mg/mmol (ACR category A3), together with haematuria
a sustained decrease in eGFR of 25% or more and a change in eGFR category within 12 months
a sustained decrease in eGFR of 15 ml/min/1.73m2 or more per year
hypertension that remains poorly controlled despite the use of at least 4 antihypertensive medicines at therapeutic doses
known or suspected rare or genetic causes of CKD
suspected renal artery stenosis

*Note the 4-variable Kidney Failure Risk Equation has replaced eGFR thresholds for referral as this is a more useful predictor of patients at risk of CKD progression.

Red Flags

If Acute Kidney Injury is suspected then refer to AKI guidelines.

For urgent advice, the on-call renal registrar (or consultant if registrar unavailable) is contactable by mobile through Southmead hospital switchboard (01179 505050)

Our advice and guidance service provides consultant advice, usually within 24 hours.

Hyperkalaemia

If K+ is ≥6.5mmol/L then emergency treatment is required via medical admission to your local hospital. However, patients who are well known to the renal team or are having dialysis may be best discussed with the on-call renal registrar as above initially.

Please also refer to the Hyperkalaemia page for further information.

What to do before referral

Please refer initially to the NBT renal service flowchart for CKD management’ which outlines the principles of CKD management.

Consider submitting a nephrology advice and guidance request which may be provide adequate guidance for ongoing management in primary care.

Referral

If referral is required, then please refer using the standard BNSSG referral template available in EMIS. Please do not use tick-box referral forms which are no longer in use.

Please address referrals to the specialist, rather than writing ‘see consultation notes below’. Please include details of:

The reason for referral
Past medical history
Current medications list

Specific investigations to perform and include as part of referral include:

blood tests (U+E, FBC, Bone Profile, Lipid profile, HbA1c)
urine dipstick (for blood and protein)
urine ACR (or urine PCR)
recent blood pressure measurements
result of Kidney Failure Risk Equation calculation

If renal tract imaging (e.g. renal ultrasound) has been performed then please provide the report of this in the referral.

Referral options:

General Adult Nephrology Clinic (NBT) via eRS (available at Southmead and South Bristol Community Hospital)
Adult Nephrology Clinic (RUH Bath) via eRS if this is more appropriate for your patient.

Prescribing in renal impairment

Prescribing medicines in renal impairment: using the appropriate estimate of renal function to avoid the risk of adverse drug reactions. Provides information on circumstances when using Cockcroft-Gault formula to calculate creatinine clearance is more appropriate than eGFR

For most drugs and for most adult patients of average build and height, estimated Glomerular Filtration Rate (eGFR) should be used to determine dosage adjustments.

Creatinine clearance (CrCl) should be calculated using the Cockcroft-Gault formula to determine dosage adjustments for:

Direct-acting oral anticoagulants (DOACs)
Patients taking nephrotoxic drugs (e.g. vancomycin and amphotericin B)
Elderly patients (aged 75 years and older)
Patients at extremes of muscle mass (BMI <18kg/m2 or >40kg/m2)
Patients taking medicines that are largely renal excreted and have a narrow therapeutic index such as digoxin and sotalol

Advanced Renal Failure

The nephrology team, palliative care team and renal supportive care team have produced Supportive Care Guidelines for Renal Patients.

These guidelines give advice on supportive care, symptom control and End of Life care for renal patients with end stage CKD.

Local hospices can also give advice and support on End of Life care.

Resources

(1)NICE guideline [NG203] Chronic kidney disease: assessment and management. Published 25 August 2021. Includes further guidance on investigation, classification, monitoring and management of complications of CKD. These complications include renal anaemia, hyperphosphataemia and CKD mineral bone disease.

(2) Kidney Failure Risk Equation

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.