** 3 months proteinuria or microalbuminuria If none of the previous criteria

1. CKD 1 CKD 2 Mild renal failure CKD 4 Severe renal failure CKD 5 End stage renal failure RCHT suggested management of Chronic Kidney Disease Review : Jan 2012 Management Suggested Renal Referral U & E’s at least 12 monthly ACR for all patients at baseline. Yearly only if at risk. Ca, PO4, ALP, Alb, Cholesterol and Hb initially only General health advice ‡ Review medication Treat hyperlipidaemia according to guidelines ACE-I / A2RB if ACR > 70mg/mmol (>2.5/ 3.5 diabetics) or other indication Aspirin if indicated (BP < 140/90mmHg) Treat BP according to BHS guidelines BP target 140/90mmHg, or 130/80 if ACR > 70mg/mmol BP > 140/90 on 4 agents Creatinine rise of 25% over 3 years (re test on fasting sample to confirm) Isolated microscopic haematuria < 50 years ACR >70 mg/mmol Micro haematuria and ACR > 30 mg/mmol Suspected systemic illness ARF with ACE-I (having stopped) eGFR > 90 Must have other evidence of kidney disease ** eGFR 60-89 As above + U & E’s 6 monthly (and Hb in CKD 3b),§ Cholesterol 12 monthly. Parathormone (PTH) only if complicated CKD and not otherwise referred# Immunise against influenza and pneumococcus Avoid nephrotoxic drugs if possible As above or eGFR fall > 5mls a year (re test on fasting sample to confirm) Complicated CKD (unexplained anaemia, Ca, PO4, bicarbonate abn, weight loss) CKD 3a 45 – 59 Moderate renal failure eGFR 30-59 CKD 3b 30 – 44 As above + U & E’s 3 monthly for stage 4, 6 weekly for stage 5§ Ca, PO4, Bicarb, ALP, Alb, Haemoglobin, 3-6 monthly PTH and ferritin 6 monthly if previous abnormal, 12 monthly if normal Dietary assessment Immunise against Hep B if appropriate Treat elevated PTH according to guidelines Renal replacement / conservative management option education Pre transplant assessment if appropriate Generally refer all patients. Possible exceptions may be: In final terminal stages of another illness Stable disease and no symptoms or complications of renal failure Further investigation or management is clearly inappropriate eGFR 15-29 eGFR <15 ** 3 months proteinuria or microalbuminuria If none of the previous criteria Persistent haematuria after urology investigations are evident, the patient is not Biopsy proven glomerulonephritis defined as CKD – no further Structural abnormality of kidney or ureter action required. ‡ Smoking cessation weight reduction aerobic exercise limiting alcohol & salt intake § Repeat in 5 days if no previous results or ? acute fall # PTH: CKD 3 not measured as screen- only if complications. CKD 4 requires test.

2. Initiation of ACE-I / A2RB Guidelines Baseline eGFR within 4 weeks Start ACE-I / A2RB Repeat eGFR at 2 weeks eGFR < 5mls/min fall eGFR 5-15mls/min fall eGFR > 25% fall Continue Continue and rpt eGFR in 4 weeks Stop and refer to nephrology Stable eGFR Continuing decline K+ > 6.0 – stop treatment and discuss with nephrology Proteinuria Creatinine measurement Guidelines Initial assessment and at least annually in the following groups Avoid eating meat for 12 hours before a formal eGFR sample Previously diagnosed CKD Renal pathology (eg GN, APKD, reflux, single kidney) Persistent proteinuria or haematuria High risk of silent obstruction Bladder voiding dysfunction, prostatic hypertrophy Urinary diversion surgery, long term ureteric stents Urinary stone disease (> 1 episode/year) High risk of silent renal parenchymal disease Hypertension, CCF, DM, IHD, CVD, PVD FH of CKD stage 5 or hereditary kidney disease Long term potentially nephrotoxic medication ACE-I, A2RB, NSAIDS, lithium, mesalazine ciclosporin, tacrolimus Multisystem disease that may affect the kidney SLE, vasculitis, myeloma, rheumatoid arthritis Patients to be tested: eGFR < 60mls/min, +ve protein on urine dipstix, diabetic screen. ACR 30 – 70 mg/mmol - retest with early morning sample > 30 mg/mmol on retest – significant for non diabetics >2.5 for men and >3.5 for women with diabetes significant Use suffix “p” when staging CKD (>30mg/mmol) Haematuria Urine dipstix. Does not need microscopy confirmation. 1+ significant. Confirm with 2 out of 3 positive results. Macroscopic haematuria to urology Urology for isolated invisible haematuria if normal renal function and > 50yrs, otherwise discuss with renal. Renal ultrasound Progressive CKD Persistent invisible haematuria Symptoms of obstruction Visible haematuria FH of APKD when >20 yrs CKD stage 4 or 5 Considered to require a renal biopsy Referrals and Information Emergency Admissions: Malignant hypertension Potassium > 7 mmol/L Acute severe illness with urine blood + protein Acute renal failure Urgent Referrals: Nephrotic syndrome Acute renal failure (not requiring admission) BP > 170/100 mmHg Systemic illness with urine blood + protein We are happy to discuss any renal case. Please telephone the renal secretaries at Treliske. We also would like to be notified of any significant event affecting any dialysis or transplant patient. Suggested web site for information: www.renal.org or www.renalpatientview.org