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

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

Prevention is possible. Early detection and management of CKD can delay disease progression and reduce adverse outcomes. Listed below are clinical guidelines for the detection, treatment, management and referral of CKD, as adapted from the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (K/DOQI) Clinical Practice Guidelines for Chronic Kidney Disease.

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
  • Systemic infections
  • Cystic kidney disease
  • Autoimmune diseases
  • Lower urinary tract obstruction
  • Drug toxicity
• CKD risk is not uniform among racial and ethnic populations. Relative risks compared to whites:

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

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

Look for 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
• Structural damage (discerned from imaging)

Diagnose.

• Evaluate for markers of kidney damage and for level of kidney function per eGFR.
• Determine underlying cause, comorbid conditions, disease severity, complications and stage of disease.
• Develop clinical action plan to prevent and slow disease progression.

CKD by Stage and Recommended Action

Source: NKF, K/DOQI Clinical Practice Guidelines for Chronic Kidney Disease, 2002

Prevent.

For patients at risk for CKD, but without clinical markers:

• Prescribe ACE inhibitor or angiotensin receptor blocker (ARB) to protect kidney function.
• Keep blood pressure below 130/80 mmHg.
• Advise tight glycemic control for patients with diabetes.
• Evaluate, monitor and treat CVD risk factors.
• Screen for CKD markers yearly or as you determine appropriate.

Treat and Manage.

For patients with clinical markers of CKD:

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

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 K/DOQI Clinical Practice Guidelines for Chronic Kidney Disease go to:
kidney.org/professionals/KDOQI/.