This site is intended for healthcare professionals

Go to /sign-in page

You can view 5 more pages before signing in

Early identification of CKD in primary care

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

Authoring team

Identification of risk groups:

  • testing for CKD should be offered if people 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
    • incidental detection of haematuria or proteinuria
  • do not use any of the following as risk factors indicating testing for CKD in adults, children and young people:
    • age
    • gender
    • ethnicity
    • obesity in the absence of metabolic syndrome, diabetes or hypertension.
  • monitor adults, children and young people for the development or progression of CKD for at least 3 years after acute kidney injury (longer for people with acute kidney injury stage 3) even if eGFR has returned to baseline
  • monitor GFR in people prescribed drugs known to be nephrotoxic such as calcineurin inhibitors and lithium. Check GFR at least annually in people receiving long-term systemic non-steroidal anti-inflammatory drug (NSAID) treatment

Testing for CKD: eGFR and albumin:creatinine ratio

  • clinicians should use urine albumin:creatinine ratio (ACR) in preference to protein:creatinine ration (PCR) in order to detect proteinuria
    • ACR 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
  • for the initial detection of proteinuria, if the ACR is between 3 mg/mmol and 70 mg/mmol, this should be confirmed by a subsequent early morning sample. If the initial ACR is 70 mg/mmol or more, a repeat sample need not be tested
  • regard a confirmed ACR of 3 mg/mmol or more as clinically important proteinuria Quantify urinary albumin or urinary protein loss as in recommendation
    • all people with diabetes, and people without diabetes with a GFR less than 60 ml/min/1.73 m^2, should have their urinary albumin/protein excretion quantified. The first abnormal result should be confirmed on an early morning sample (if not previously obtained)
    • quantify by laboratory testing the urinary albumin/protein excretion of people with an eGFR 60 ml/min/1.73 m^2 or more if there is a strong suspicion of CKD

Frequency of monitoring - Frequency of monitoring of GFR (number of times per year, by GFR and ACR category) for people with, or at risk of, CKD

  • use table below to guide the frequency of GFR monitoring (per year) for people with, or at risk of, CKD, but tailor it to the person according to:
    • the underlying cause of CKD
    • past patterns of eGFR and ACR (but be aware that CKD progression is often nonlinear)
    • comorbidities, especially heart failure
    • changes to their treatment (such as renin-angiotensin-aldosterone system [RAAS] antagonists, NSAIDs and diuretics)
    • intercurrent illness whether they have chosen conservative management of CKD

 

GFR ( ml/min/1.73 m^2) and ACR categories and risk of adverse outcomes

 

A1

< 3 mg/mol (normal to mildly increased)

A2

3 -30 mg/mol (moderately increased)

A3

> 30mg/mol (severely increased)

G1

>= 90 ml/min/1.73 m^2

(Normal and High)

check eGFR <=1 time per year

check eGFR 1 time per year

check eGFR >=1 time per year

G2

60-89 ml/min/1.73 m^2

(Mild reduction related to normal range for young adult)

check eGFR <=1time per year

check eGFR 1 time per year

check eGFR >=1time per year

G3a

45-59 ml/min/1.73 m^2

(mild-moderate reduction)

check eGFR 1time per year

check eGFR 1 time per year

check eGFR 2 times per year

G3b

30-44 ml/min/1.73 m^2

(moderate-severe reduction)

check eGFR <=2 times per year

check eGFR 2 times per year

check eGFR >=2 times per year

G4

15-29 ml/min/1.73 m^2

(severe reduction)

check eGFR 2 times per year

check eGFR 2 times per year

check eGFR 3 times per year

G5

< 15 ml/min/1.73 m^2

(kidney failure)

check eGFR 4 times per year

check eGFR >=4 times per year

check eGFR >=4 times per year

 

ACR (albumin creatinine ratio) category

ACR (mg/mmol)

A1

<3

A2

3-30*

A3

>30**

Using the Table - some examples:

  • CKD G3a A1 - CKD stage 3 A with an ACR less than 3 mg/mmol has a suggested requirement of x1 GFR measurement per year i.e. yearly monitoring

  • CKD G3a A3 - CKD stage 3A with an ACR > 30mg/mmol has a suggested requirement of x2 GFR measurements per year i.e. 6 monthly monitoring

  • CKD G5 A2- CKD stage 5 with an ACR between 3 and 30 mg/mmol has suggested requirement of >=4 GFR measurements per year

* Relative to young adult level

** Including nephrotic syndrome (ACR usually >220 mg/mmol)

Abbreviations: ACR, albumin:creatinine ratio; CKD, chronic kidney disease

Monitor people for the development or progression of CKD for at least 2-3 years after acute kidney injury, even if serum creatinine has returned to baseline

  • where a highly accurate measure of GFR is required - for example, during monitoring of chemotherapy and in the evaluation of renal function in potential living donors - consider a gold standard measure (inulin, 51Cr-EDTA, 125I-iothalamate or iohexol)
  • Defining progression
    • define accelerated progression of CKD as:
      • a sustained decrease in GFR of 25% or more and a change in GFR category within 12 months
      • or a sustained decrease in GFR of 15 ml/min/1.73 m2 per year

    • take the following steps to identify the rate of progression of CKD:
      • obtain a minimum of 3 GFR estimations over a period of not less than 90 days
      • in people with a new finding of reduced GFR, repeat the GFR within 2 weeks to exclude causes of acute deterioration of GFR- for example, acute kidney injury or starting renin-angiotensin system antagonist therapy

    • be aware that people with CKD are at increased risk of progression to endstage kidney disease if they have either of the following:
      • a sustained decrease in GFR of 25% or more over 12 months or
      • a sustained decrease in GFR of 15 ml/min/1.73 m^2 or more over 12 months

Reference:


Create an account to add page annotations

Add information to this page that would be handy to have on hand during a consultation, such as a web address or phone number. This information will always be displayed when you visit this page

The content herein is provided for informational purposes and does not replace the need to apply professional clinical judgement when diagnosing or treating any medical condition. A licensed medical practitioner should be consulted for diagnosis and treatment of any and all medical conditions.

Connect

Copyright 2024 Oxbridge Solutions Limited, a subsidiary of OmniaMed Communications Limited. All rights reserved. Any distribution or duplication of the information contained herein is strictly prohibited. Oxbridge Solutions receives funding from advertising but maintains editorial independence.