Population: Adults with chronic kidney disease.
Organizations
KDIGO 2021, NKF-KDOQI 2014, NICE 2021, VA/DoD 2019
Recommendations
Evaluation
–Establish CKD stage by eGFR and presence of albuminuria with abnormalities being present for at least 3 mo. In patients with a new finding of eGFR of <60 mL/min/1.73 m2, repeat the study in 2 wk to confirm this finding.
–Establish etiology. Refer to urology or nephrology if appropriate.1
• Etiology: Assign probable cause of CKD based on absence or presence of systemic disease and the location within the kidney of observed or presumed pathologic-anatomic abnormalities.
• GFR category2:
G1: GFR > 90 (mL/min/1.73 m2).
G2: GFR 60–89.
G3a: GFR 45–59.
G3b: GFR 30–44.
G4: GFR 15–29.
G5: GFR < 15.
• Albuminuria category by urine albumin-to-creatinine ratio (ACR): (ACR is recommended over protein-to-creatinine ratio (PCR) because of its sensitivity for low levels of proteinura)
A1: ACR < 3 (mg/mmol).
A2: ACR 3–30.
A3: ACR > 30.
– Evaluate for chronicity.
• In those with GFR < 60 mL/min/1.73 m2 (GFR categories G3a–5), evaluate history of prior indicators for kidney disease and prior measurements.
• If duration is >3 mo, then CKD is confirmed. If not >3 mo, CKD is not confirmed or is unclear.
Management
–Treat the underlying cause of the CKD.
–Control BP and individualize BP targets based on age, coexisting comorbidities, presence of retinopathy, and tolerance of treatment. See Ch 19: Cardiovascular Disorders – Hypertension for discussion of BP targets.
–Use ACE-I or ARB in CKD and ACR > 70 or CKD with DM and ACR > 30.
–Target a hemoglobin A1c of approximately 7% in people with diabetes and CKD, although HbA1c should be individualized to a range of <6.5% to <8% based on multiple factors. (KDIGO)
–First-line glycemic control for CKD with DM includes metformin1 and SGLT22 inhibitor, with additional therapy added as needed.
–Lower protein intake to 0.8 g/kg/d in adults with diabetes and nondiabetics with GFR categories G4–5.
–Recommend salt intake of <2 g/d.
–Supplement bicarbonate in CKD with metabolic acidosis.
–Give oral iron therapy every other day for Stage 3 or worse CKD with anemia.
–Use erythropoietic-stimulating agents only if hemoglobin <10 g/dL.
–Refer to nephrology for consideration of renal replacement therapy after shared decision-making if 5-y risk of RRT is >5%, if ACR > 70, or on >4 antihypertensives. (NICE)
–Recommend immunizations for influenza, Tdap, 13-valent pneumococcal conjugate vaccine, hepatitis B virus, zoster, MMR.
Surveillance
–Monitor for CKD progression with annual GFR and ACR. Assess more frequently if higher risk for progression based on GFR and ACR.
–Monitor for complications in CKD stage 3a–5 with hemoglobin, electrolytes, calcium, phosphate, intact parathyroid hormone (PTH), 25-OH vitamin D.
Practice Pearls
• Recommendation for low protein (0.6–0.8 g/kg/d) diet: If offered to CKD stage 3 and 4 patients, it may slow progression to ESRD, but also may be associated with risk of calorie malnutrition; thus, multidisciplinary support is recommended with use (VA/DoD). Alternate committees recommend to not offer low-protein diets (dietary protein intake less than 0.6–0.8 g/kg/d) (NICE).
• eGFR calculators that incorporate race are based on flawed data and may exacerbate health inequities. Use caution when adjusting eGFR calculations based on race. (N Engl J Med. 2020;383(9):874-882)
Sources
–https://www.ajkd.org/article/S0272-6386(14)00491-0/pdf
–Kidney Int. 2020;98:S1-S115.
–Kidney Int. 2021;99:S1-S87.
–NICE. Chronic kidney disease: assessment and management. NICE Guideline. 25 August 2021. www.nice.org.uk/guidance/ng203
–VA/DoD. VA/DoD Clinical Practice Guideline for the Management of Chronic Kidney Disease. 2019. https://www.healthquality.va.gov/guidelines/CD/ckd/VADoDCKDCPGProviderSummaryFinal5082142020.pdf
Population: Adults and children with CKD and mineral or bone disorders.
Organization
KDIGO 2017
Recommendations
–Monitor serum calcium, phosphorus, immunoreactive parathyroid hormone (iPTH), and alkaline phosphatase levels:
• Beginning with Stage G3a CKD (adults).
• Beginning with Stage G2 CKD (children).
–Measure 25-OH vitamin D levels beginning in stage G3a CKD.
–Treat all vitamin D deficiency with vitamin D supplementation with standard recommended dosing. Decisions to treat should be based on trends of vitamin D levels, not a single level.
–In Stages G3–5 CKD, consider a bone biopsy before bisphosphonate therapy if a dynamic bone disease is a possibility.
–In Stages G3–5 CKD, aim to normalize calcium and phosphorus levels.
–In Stage G5 CKD, seek to maintain a PTH level of approximately 2–9 times the upper normal limit for the assay.
Source
–https://kdigo.org/wp-content/uploads/2017/02/KDIGO_CKD_MBD_Guideline_r6.pdf