Almost 33 million American adults have kidney disease. Millions more are at risk, but don’t know it.¹
More than 46,000 (8%) of the 576,000 Americans who have end-stage renal disease (ESRD) are Texans. ^{2, 3}
Average costs of treatment with dialysis or kidney transplant are $66,000 per patient per year.¹
The number of dialysis patients in Texas has more than tripled since 1990. (ESRD Network 14).²
Diabetes, hypertension and cardiovascular disease (CVD) are major risk factors for CKD.
CVD is the leading cause of death among patients with CKD.
Simple laboratory tests can detect CKD at early stages.
Early detection and management of CKD can prevent or delay progression to kidney failure and the need for renal replacement therapy, (RRT).

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Chronic Kidney Disease (CKD): Prevention, Detection, Treatment and Management

What is Chronic Kidney Disease (CKD)?

Chronic kidney disease (CKD) is a gradual and progressive reduction in kidney function, indicated by the presence of a marker of kidney damage for three or more months.

A urine albumin-to-creatinine ratio greater than 30 mg of urinary albumin per gram of urinary creatinine, with or without decreased GFR; or
A glomerular filtration rate (GFR) less than 60 mL per minute per 1.73 m², with or without kidney damage.

What Can Primary Care Providers (PCPs) Do To Prevent, Manage and Treat CKD?

Recognize who is at risk.
Screen at-risk patients.
Diagnose based on presence of CKD markers.
Manage and control.
Treat and manage.
Know when to refer patient to specialist.

Listed below are clinical guidelines for the detection, management, treatment and referral of CKD, as adapted from the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (KDOQI) Clinical Practice Guidelines for Chronic Kidney Disease.

Applying Clinical Guidelines for CKD

1. Determine patient risk.

All patients should be evaluated, as part of their routine physical examination, to determine the risk of developing CKD.
Diabetes and hypertension are the leading causes of CKD and kidney failure. Individuals with cardiovascular disease (CVD) or a family history of kidney disease are also at increased risk.
Other clinical risk factors include:
- Glomerulonephritis
- Cystic kidney disease
- Metabolic syndrome
- Autoimmune diseases
- Systemic infections
- Lower urinary tract obstruction
- Drug toxicity
CKD risk is not uniform among racial and ethnic populations. Relative risks compared to Whites:

2. Screen at-risk patients.

“Spot” urine albumin-to-creatinine ratio to detect albuminuria
Serum creatinine applied to a predication equation to estimate GFR (eGFR)
Blood pressure measurement

3. Diagnose.

Evaluate for markers of kidney damage and for level of kidney function per eGFR.
CKD Markers
Albuminuria: more than 30 mg of urinary albumin per gram of urinary creatinine

eGFR less than 60 mL per minute per 1.73 m²

CKD Markers
Albuminuria: more than 30 mg of urinary albumin per gram of urinary creatinine eGFR less than 60 mL per minute per 1.73 m²

Determine underlying cause, co-morbid conditions, disease severity, complications and stage of disease.
Develop clinical action plan to prevent and slow disease progression.

CKD by Stage and Recommended Action

Stage	Description	GFR	Action
	Normal kidney function	>60	Assess for CKD risk factors
	Increased risk for kidney disease	>60(with CKD risk factors)	Treat/manage CKD risk factors Screen for CKD
1	Kidney damage with normal or increased GFR	>90	Diagnose/treat to slow progression Evaluate for CVD Educate patient on disease management Manage co-morbid conditions
2	Kidney damage with mild decrease in GFR	60-89	Estimate progression Treat co-morbid conditions
3	Kidney damage with moderate decrease in GFR	30-59	Evaluate/treat complications Refer to nephrologist
4	Kidney damage with severe decrease in GFR	15-29	Educate patient on kidney replacement options Prepare for renal replacement therapy
5	Kidney failure	<15	Kidney replacement by dialysis or transplant

Source: NKF, KDOQI Clinical Practice Guidelines for Chronic Kidney Disease, 2002

4. Manage and Control.

For patients with diabetes, hypertension, or CVD, but without clinical markers of CKD:

Prescribe ACE Inhibitor (ACEI) or angiotensin receptor blocker (ARB) to protect kidney function.
Keep blood pressure below 130/80 mmHg.
Advise glycemic control for patients with diabetes.
Treat and monitor co-morbid conditions.
Screen for CKD markers at least yearly.

5. Treat and Manage

For patients with clinical markers of CKD:

Use ACEI or ARB.
Maintain blood pressure below 130/80 mmHg.*
Maintain strict glycemic control: A1c less than 7% for patients with diabetes.*
Monitor hemoglobin and phosphorous.
Manage and treat CVD risk factors.
Refer for medical nutrition therapy.
Encourage patient self-management.
Assess progression, adjust medications to current eGFR.
Manage/treat co-morbidities (CVD, diabetes, hypertension).
Manage/treat complications (hypertension, anemia, dyslipidemia, mineral and bone disease).
Provide ongoing primary care.

*Goals must be individualized.

6. Manage with Nephrology.

Consult at stage 1 if hematuria or significant proteinuria is present.
Consult at stage 2 if GFR declines more than 4 mL per minute per year.
Refer at stage 3 or if eGFR is less than 30 mL per minute per 1.73 m².
Prepare for replacement therapy (RRT) at stage 4.
- Educate patient on RRT options.
- Prepare arteriovenous (AV) fistula at least 6 weeks to several months prior to hemodialysis.
Provide ongoing primary care.

For more information about the KDOQI Clinical Practice Guidelines for Chronic Kidney Disease go to:
kidney.org/professionals/KDOQI/.

African-Americans	3.8 X
Native Americans	2.0 X
Hispanics	1.5 X
Asian/Pacific Islanders	1.3 X