Chronic Kidney Disease –

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    Chronic Kidney Disease

    Identifcation, Evaluation and Management o PatientsE ective Date: e te e e te e

    Scope

    The st a t o this guideline ovides eco endations o the investigation and evaluation o adultatients ( 9+) at isk o ch onic kidney disease (CKD). The second a t o this guideline ocuses on

    the anage ent o adult atients with known CKD and includes ca e o jectives and atient sel -anage ent.

    ecialized anage ent o esta lished CKD e.g. e yth o oietic agents o ane ia enal e lace ent

    the a y and t eat ent o calciu hos hate o a athy oid ho one (PTH) a no alities is eyondthe sco e o this guideline.

    Diagnostic Code: (ch onic enal ailu e)

    Part 1: Identifcation and Evaluation o Patients at Risk or CKD

    This section cove s:I. P evention and isk acto sII. InvestigationIII. Diagnosis and staging o CKDIV. Dete ining the cause o CKD

    V. Evaluating atients with a no al sc eening tests VI. Flow diag a o evaluating and anaging sus ected CKD

    I. Prevention and risk actorsIdenti y atients at isk o CKD ased u on a di ected edical and su gical histo y including co-

    o idities (e.g. dia etes ca diovascula disease [CVD]) and dieta y social de og a hic andcultu al acto s a eview o sy to s and hysical exa ination. Po ulations at inc eased iskinclude those with: Dia etes Hy e tension with o without CVD A a ily histo y o kidney disease eci c high- isk ethnic g ou s: Fi st Nations Paci c Islande s A ican descent and Asians

    Note: Age > 6 yea s is associated with an inc eased isk o i ai ed kidney unction ut evidence isinsu cient to eco end sc eening solely on the asis o age.

    II. InvestigationIt is eco ended that hysicians sc een at- isk o ulations eve y - yea s de ending u onclinical ci cu stances (e.g. yea ly o e sons with dia etes) using se u c eatinine and andou ine tests ( ac osco ic/ ic osco ic u inalysis and ACR). Esti ated glo e ula lt ation ate

    BRITISHCOLUMBIA

    MEDICALASSOCIATION

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    2/20ChroniC Kidney d isease identifiCation , e valuation and M anageMent of P atientsDiagnostic Code:

    (eGFR) is the est a ke o CKD and is co uted o the se u c eatinine. Most la s inB itish Colu ia (BC) auto atically e o t eGFR when a se u c eatinine is o de ed. ( ee

    A endix B o u the in o ation on eGFR calculations.)

    Investigational tests

    a) e u testing: eGFR values:

    < 6 L/ in and persistent ( esent o > 3 onths) indicates su stantial eduction in kidneyunction.

    > 6 L/ in and < L/ in in the a sence o u ine a no alities o st uctu ala no alities on i aging studies (e.g. ult asound) does not indicate kidney disease.

    Age > 7 yea s: accu acy o eGFR o atients ove 7 is questiona le and ayunde esti ate t ue kidney unction. Values o eGFR < 4 should e conside ed as a likelyindicato o dec eased enal unction and e it u the wo k-u . Values etween4 and 6 ay efect no al va iation in the a sence o othe conditions howeve caution isstill eco ended with es ect to edications dye and isk o acute kidney inju y with seve eillnesses. Co elation with clinical condition is eco ended.

    Age > yea s: equation o eGFR is o le atic and isk o og ession o CKD isnot known. In the a sence o othe eta olic o he atological a no alities a conse vativea oach is eco ended. Values etween 4 and 6 ay efect no al va iationin the a sence o othe conditions. Caution is still eco ended with es ect to

    edications dye and isk o acute kidney inju y with seve e illnesses. Esti ates ased on se u c eatinine easu e ents (eGFR) ay e un elia le in atients with

    ve y la ge o s all ody ha itus those on s eci c diets (ve y high o ve y low otein) and inatients eceiving edications that inte e e with the exc etion o c eatinine (e.g. t i etho i

    and sul a ethoxazole ci ofoxacin eno ate). Exe cise diet and/o hyd ation status ay a ect kidney unction esti ates o the deg ee

    o al u inu ia/ oteinu ia. I aseline tests a e a no al o su sequent tests a e signi cantlydi e ent o aseline con ation y e eat testing is wa anted.

    ) U ine testing: ac osco ic/ ic osco ic analysis and al u in/c eatinine atio (ACR) values Rando u ine tests o ac osco ic/ ic osco ic u inalysis and ACR: igni cant a no alities: e sistent white lood cells o ed lood cells in the a sence

    o in ection o inst u entation; esence o any cellula casts is always athological. ACR elevation (> . g/ ol ales; > . g/ ol e ales) on out o 3 se ial tests

    e o ed week to onths a a t indicates ic o-vascula disease +/- glo e uladisease.

    U ine test a no alities even with e sistent eGFR values 6 l/ in indicate a no alkidney unction eithe as an isolated condition o as a sy to o a syste ic disease.

    4-hou u ine collections a e not necessa y in ost cases. ACR is the ethod that allows one to test o al u in esent in quantities a ove no al

    ut elow the detecta le ange on standa d di sticks. In the ast the wo d ic oal u inhas een used ut this ay lead to a alse i ession that the e is a di e ent oleculewhen the e is not. Thus ACR is the e e ed ethod y which to assess a no allevels o al u in. Note that this guideline uses the th esholds ado ted y the CanadianDia etes Association o the detection o ic oal u inu ia. As ethods i ove and

    u the data eco es availa le these cuto s ay e evised. e ial ACR tests can no allye inco o ated into the outine visit schedule.

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    3/20C hroniC Kidney d isease identifiCation , e valuation and M anageMent of P atients Diagnostic Code:

    Stage Description

    1 Kidney damageb with normal or eGFR2 Kidney damageb with mild eGFR3 Moderate in eGFR4 Severe in eGFR5 Kidney ailure

    Acting on test esults

    No al: e eat annually o as clinically indicated and onito lood essu e. A no al: con and evaluate (Ta le elow).

    III. Diagnosis and staging o CKDCKD is de ned as eGFR < 6 L/ in o > 3 onths o evidence o kidney da age ( athologic

    a no alities o a ke s o da age including a no alities in lood o u ine tests o i agingstudies). I CKD is esent dete ine its stage ased on eGFR u inalysis and ACR. The ollowingstaging syste designed y the U National Kidney Foundation with inte national in ut is

    eco ended to acilitate assess ent and anage ent o CKD. 3

    Table 1. Stages o CKD

    Potential Complications of reduced eGFRa (alphabetically)

    Anemia, including unctional iron de ciency BP increases Calcium absorption decreases Dyslipidemia/heart ailure/volume overload Hyperkalemia Hyperparathyroidism Hyperphosphatemia Le t ventricular hypertrophy Metabolic acidosis Malnutrition potential (late)

    NOTE :a The listed co lications a e not s eci c to CKD ut tend to occu with inc easing equency and a e o e di ectly

    att i uta le to CKD at lowe eGFR (e.g. stages 4 and ). I co lications a e noted at an ea ly stage o CKDinvestigation o alte native causes is eco ended e.g. o ound ane ia at eGFR o l/ in is likely not

    att i uta le to low kidney unction alone.Kidney da age is de ned as athological a no alities (kidney io sy esults) o a ke s o da age includinga no alities in lood o u ine tests ( otein/al u in in the u ine ed lood cells white lood cells o casts) o i agingstudies.

    IV. Determining the cause o CKDI ai ed kidney unction is o ten ulti- acto ial. I ossi le dete ine a i a y cause okidney disease in all atients. Kidney ult asound is a use ul exa ination to identi y olycystickidney disease cance stones and o st uction. Disc e ancy in kidney size ay signal clinicallysigni cant enal a te y stenosis (the wo k u o enal a te y stenosis is eyond the sco e o thisguideline).

    Even i a i a y cause see s o vious (e.g. hy e tension dia etes) the ossi ility o a se iousunde lying diso de (e.g. vasculitis syste ic lu us e ythe atosis) ust e conside ed in atientswith:

    A no al u inalysis e.g. oteinu ia he atu ia cellula casts o co inations the eo . Ra id sustained decline in kidney unction ( eGFR > - %/yea ) des ite e edy o

    eve si le eci itants e.g. volu e cont action e ile illness edications. Consistent i ai ent o kidney unction in the a sence o isk acto s. Constitutional sy to s suggesting syste ic illness. udden o seve e onset o sy to s e.g. ede a un elated to hea t o live disease.

    eGFRa

    9060-8930-5915-29

    < 15 oron dialysis

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    Re e to an inte nist o ne h ologist o u the evaluation i an etiology cannot e dete ined.Note that occasionally a sc eening test will identi y a se ious syste ic disease o ea ly stageso an acute illness. In atients with active u ine sedi ents ( c casts o cellula casts otein)constitutional sy to s o unex lained seve ity o kidney dys unction o t consultation with as ecialist and/o e-evaluation o tests is indicated.

    V. Evaluating patients with abnormal screening tests

    Patient anage ent should efect CKD stage and eGFR u inalysis and ACR esults (see Ta le ).

    Table 2. Evaluating patients with abnormal screening testsEvaluating patients with abnormal screening tests a

    Stage Other Results Recommendations b

    Stage 1 or 2; eGFR 60mL/minplus evidence okidney damagec

    Stage 3; eGFR =30-59 mL/min

    Stage 4; eGFR =15-29 mL/min

    Stage 5; eGFR 20 male;> 28 emale)

    Urinalysis normalbut ACR equivocal(2-20 male; 2.8-28

    emale)

    Urinalysis abnormal or

    ACR abnormal(> 20 male;> 28 emale)

    Regardless o otherresults

    Regardless o otherresults

    Determine caus