Chronic kidney disease: early identification and management of chronic kidney disease in adults in primary and secondary care

National Institute for Health and Clinical Excellence

Introduction

• Chronic kidney disease (CKD) is common, frequently unrecognised and often exists together with other conditions (for example, cardiovascular disease and diabetes). When advanced, it also carries a higher risk of mortality

• There is evidence that treatment can prevent or delay the progression of CKD, reduce or prevent the development of complications and reduce the risk of cardiovascular disease. However, because of a lack of specific symptoms people with CKD are often not diagnosed, or diagnosed late when CKD is at an advanced stage

• On average 30% of people with advanced kidney disease are referred late to nephrology services from both primary and secondary care, causing increased mortality and morbidity

• Strategies aimed at earlier identification and (where possible) prevention of progression to established renal failure are therefore clearly needed. This clinical guideline seeks to address these issues

Key priorities for implementation

• To detect and identify proteinuria, use urine albumin: creatinine ratio (ACR) in preference, as it has greater sensitivity than protein: creatinine ratio (PCR) for low levels of proteinuria. For quantification and monitoring of proteinuria, PCR can be used as an alternative. ACR is the recommended method for people with diabetes

• Offer angiotensin-converting enzyme (ACE) inhibitors/angiotensin II receptor blockers (ARBs) to non-diabetic people with CKD and hypertension and ACR ≥30 mg/mmol (approximately equivalent to PCR ≥50 mg/mmol, or urinary protein excretion ≥0.5 g/24 h)*

• Stage 3 CKD should be split into two subcategories defined by:
• GFR 45–59 ml/min/1.73 m2 (stage 3A)
• GFR 30–44 ml/min/1.73 m2 (stage 3B)

• People with CKD in the following groups should normally be referred for specialist assessment:
• stage 4 and 5 CKD (with or without diabetes)
• higher levels of proteinuria (ACR ≥70 mg/mmol, approximately equivalent to PCR ≥100 mg/mmol, or urinary protein excretion ≥1 g/24 h) unless known to be due to diabetes and already appropriately treated
• proteinuria (ACR ≥30 mg/mmol, approximately equivalent to PCR ≥50 mg/mmol, or urinary protein excretion ≥0.5 g/24 h) together with haematuria
• rapidly declining estimated glomerular filtration rate (eGFR) (>5 ml/min/1.73 m2 in 1 year, or >10 ml/min/1.73 m2 within 5 years)
• hypertension that remains poorly controlled despite the use of at least four antihypertensive drugs at therapeutic doses (see ‘Hypertension: management of hypertension in adults in primary care’ [NICE clinical guideline 34])
• people with, or suspected of having, rare or genetic causes of CKD
• suspected renal artery stenosis

• Offer people testing for CKD if they have any of the following risk factors:
• diabetes
• hypertension
• cardiovascular disease (ischaemic heart disease, chronic heart failure, peripheral vascular disease and cerebral vascular disease)
• structural renal tract disease, renal calculi or prostatic hypertrophy
• multisystem diseases with potential kidney involvement—for example, systemic lupus erythematosus
• family history of stage 5 CKD or hereditary kidney disease
• opportunistic detection of haematuria or proteinuria

• Take the following steps to identify progressive CKD:
• obtain a minimum of three GFR estimations over a period of not less than 90 days
• in people with a new finding of reduced eGFR, repeat the eGFR within 2 weeks to exclude causes of acute deterioration of GFR—for example, acute kidney injury or initiation of ACE inhibitor/ARB therapy
• define progression as a decline in eGFR of >5 ml/min/1.73 m2 within 1 year, or >10 ml/min/1.73 m2 within 5 years
• focus particularly on those in whom a decline of GFR continuing at the observed rate would lead to the need for renal replacement therapy within their lifetime by extrapolating the current rate of decline

• In people with CKD aim to keep the systolic blood pressure below 140 mmHg (target range 120–139 mmHg) and the diastolic blood pressure below 90 mmHg^†

*Two different ACR thresholds are given in the guideline for initiating ACE inhibitor treatment in people with CKD and proteinuria. The potential benefit of ACE inhibitors in this context is greatly increased if the person also has diabetes or hypertension, and in these circumstances, a lower threshold is applied. The evidence base at present does not allow thorough analysis of all scenarios and the GDG based these decisions on clinical experience as well as what evidence there is.

^†The GDG searched for and appraised evidence on blood pressure control, and did not set out to establish definitive safe ranges of blood pressure in CKD. The evidence presented in the full guideline does not therefore include safety of low blood pressure, but some such evidence does exist. Existing hypertension guidelines such as the NICE hypertension guideline (NICE clinical guideline 34) give a range rather than just an upper limit and clinicians find this clear guidance useful. The GDG therefore set out a range of blood pressure targets, given in these recommendations, which in their clinical experience will inform good practice in CKD.