Guidance

Key priorities for implementation

Key priorities for implementation

The following recommendations have been identified as priorities for implementation. The full list of recommendations is in section 1.

Investigations for chronic kidney disease

  • Clinical laboratories should:

    • use the Chronic Kidney Disease Epidemiology Collaboration (CKD‑EPI) creatinine equation to estimate GFRcreatinine, using creatinine assays with calibration traceable to standardised reference material

    • use creatinine assays that are specific (for example, enzymatic assays) and zero-biased compared with isotope dilution mass spectrometry (IDMS)

    • participate in a UK national external quality assessment scheme for creatinine. [new 2014]

  • Consider using eGFRcystatinC at initial diagnosis to confirm or rule out CKD in people with:

    • an eGFRcreatinine of 45–59 ml/min/1.73 m2, sustained for at least 90 days and

    • no proteinuria (albumin:creatinine ratio [ACR] less than 3 mg/mmol) or other marker of kidney disease. [new 2014]

  • Do not diagnose CKD in people with:

    • an eGFRcreatinine of 45–59 ml/min/1.73 m2 and

    • an eGFRcystatinC of more than 60 ml/min/1.73 m2 and

    • no other marker of kidney disease. [new 2014]

  • Offer testing for CKD using eGFRcreatinine and ACR to people with any of the following risk factors:

    • diabetes

    • hypertension

    • acute kidney injury (see recommendation 1.3.9)

    • cardiovascular disease (ischaemic heart disease, chronic heart failure, peripheral vascular disease or cerebral vascular disease)

    • structural renal tract disease, recurrent renal calculi or prostatic hypertrophy

    • multisystem diseases with potential kidney involvement – for example, systemic lupus erythematosus

    • family history of end-stage kidney disease (GFR category G5) or hereditary kidney disease

    • opportunistic detection of haematuria. [new 2014]

Classification of chronic kidney disease

  • Classify CKD using a combination of GFR and ACR categories (as described in table 1). Be aware that:

    • increased ACR is associated with increased risk of adverse outcomes

    • decreased GFR is associated with increased risk of adverse outcomes

    • increased ACR and decreased GFR in combination multiply the risk of adverse outcomes. [new 2014]

Table 1 Classification of chronic kidney disease using GFR and ACR categories

Table 1 Classification of chronic kidney disease using GFR and ACR categories

Frequency of monitoring

  • Use table 2 to guide the frequency of GFR monitoring 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 non-linear)

    • 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. [new 2014]

Table 2 Frequency of monitoring of GFR (number of times per year, by GFR and ACR category) for people with, or at risk of, CKD

Table 2 Frequency of monitoring of GFR (number of times per year, by GFR and ACR category) for people with, or at risk of, CKD

  • 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. [new 2014]

  • National Institute for Health and Care Excellence (NICE)