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