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Chronic kidney disease

Definition
CKD is defined as the presence of kidney damage persisting for > 3 months, which is manifested by decreased kidney function or albuminuria, measured by eGFR.
1
Pathophysiology
The most common causes of CKD include diabetes and hypertension. Other causes include infectious glomerulonephritis, renal vasculitis, ureteral obstruction, genetic alterations, and autoimmune diseases.
2
Disease course
CKD may be asymptomatic or result in vague symptoms, such as excessive tiredness, itching, sleep disturbance, lack of concentration, bone/joint pain, loss of appetite, loss of muscle strength, dyspnea, muscle spasm, and restless legs. Disease progression may lead to ESRD with uremic symptoms, and death.
3
Prognosis and risk of recurrence
The mortality of patients ≤ 60 years and > 60 years with CKD requiring hospital admission is 13.9% and 41.0%, respectively.
4
Key sources
The following summarized guidelines for the evaluation and management of chronic kidney disease are prepared by our editorial team based on guidelines from the American Academy of Family Physicians (AAFP 2023), the European Society of Hypertension (ESH 2023), the United Kingdom Kidney Association (UKKA 2023; 2021; 2017; 2011), the American Diabetes Association (ADA 2023), the European Society of Cardiology (ESC 2023), the American College of Radiology (ACR 2023; 2021), the Kidney Disease: Improving Global Outcomes Foundation (KDIGO 2022; 2021; 2020; 2017; 2013; 2012; 2009; 2008), the Canadian Cardiovascular Society (CCS 2022), the Infectious Diseases Society of America (IDSA/AASLD 2020), the Japanese Society of Nephrology (JSN 2019), the Diabetes Canada (DC 2018), the American College of Physicians (ACP 2016; 2013), the European Renal Best Practice Foundation (ERBP 2015), the Infectious Diseases Society of America (IDSA 2014), the Canadian Society of Nephrology (CSN 2014), the Japanese Society of Dialysis Therapy (JSDT 2013), the U.S. Preventive Services Task Force (USPSTF 2012), and the American Society for Parenteral and Enteral Nutrition (ASPEN 2010).
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Guidelines

1.Screening and diagnosis

Indications for screening, asymptomatic patients, ACP: do not obtain screening for CKD in asymptomatic adults without risk factors for CKD.
D
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  • Indications for screening (diabetic patients)

  • Indications for screening (pediatric patients)

  • Diagnostic criteria

2.Classification and risk stratification

Risk stratification: identify the following variables in predicting risk for outcome of CKD:
cause of CKD
GFR category
albuminuria category
other risk factors and comorbid conditions
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  • Classification

3.Diagnostic investigations

Serum creatinine: obtain serum creatinine and use a GFR estimating equation for initial assessment.
B
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  • Cystatin C

  • Renal ultrasound

  • Evaluation of proteinuria

  • Evaluation of albuminuria

  • Evaluation of hypertension

  • Evaluation of dyslipidemia

  • Evaluation of mineral and bone disorders

  • Evaluation for etiology

  • Screening for anemia

  • Screening for HCV infection

  • Screening for PAD

4.Medical management

General principles: manage people with progressive CKD in a multidisciplinary care setting.
B
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  • Renal adjustment of medications

  • SGLT-2 inhibitors

  • Uric acid-lowering agents

  • Management of microalbuminuria

  • Management of hypertension (BP targets)

  • Management of hypertension (physical activity)

  • Management of hypertension (sodium intake)

  • Management of hypertension (RAAS blockers)

  • Management of hypertension (CCBs)

  • Management of hypertension (diuretics)

  • Management of hypertension (potassium binders)

  • Management of hypertension (SGLT-2 inhibitors)

  • Management of hypertension (kidney transplant recipients)

  • Management of hypertension (pediatric patients)

  • Management of hypertension (patients with CVD)

  • Management of hypertension (patients with nephrosclerosis and renal artery stenosis)

  • Management of dyslipidemia

  • Management of electrolyte derangements

  • Management of hyperphosphatemia

  • Management of hyperparathyroidism

  • Management of anemia (iron therapy)

  • Management of anemia (ESA therapy, initiation)

  • Management of anemia (ESA therapy, choice of agent)

  • Management of anemia (ESA therapy, route of administration)

  • Management of anemia (ESA therapy, dosing)

  • Management of anemia (ESA therapy, maintenance)

  • Management of anemia (ESA therapy, RBC transfusion)

  • Treatments with no evidence for benefit

  • End-of-life care

5.Nonpharmacologic interventions

Weight loss: advise achieving or maintaining a healthy weight (BMI 20 to 25).
B

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  • Physical activity

  • Nutritional support

  • Salt and water intake

  • Protein intake

  • Alcohol intake

  • Smoking cessation

6.Therapeutic procedures

Renal replacement therapy, indications, CSN: adopt an intent-to-defer over an intent-to-start-early approach for the initiation of chronic dialysis in adult patients with anEGFR < 15 mL/min/1.73 m².
B

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  • RRT (evaluation of fistula malfunction)

  • RRT (management of fistula malfunction)

7.Surgical interventions

Kidney transplantation: as per JSN 2019 guidelines, consider performing preemptive kidney transplantation in all suitable patients whenever a donor is available.
C

8.Specific circumstances

Pediatric patients, screening: consider obtaining urinary screening at 3 years of age and throughout school age to detect CKD at an early stage, thus, facilitating early management and improving the renal prognosis in pediatric populations.
C

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  • Pediatric patients (risk assessment)

  • Pediatric patients (physical activity)

  • Pediatric patients (protein intake)

  • Pediatric patients (immunizations)

  • Pediatric patients (management of hypertension)

  • Pediatric patients (management of mineral and bone disorder)

  • Pediatric patients (management of growth stunting)

  • Pediatric patients (kidney transplantation)

  • Pediatric patients (patients with HIV infection)

  • Elderly patients (evaluation)

  • Elderly patients (prognostic scores)

  • Elderly patients (physical activity)

  • Elderly patients (nutritional assessment)

  • Elderly patients (glycemic targets)

  • Elderly patients (renal adjustment of medications)

  • Elderly patients (BP targets)

  • Elderly patients (lipid-lowering therapy)

  • Elderly patients (RRT)

  • Elderly patients (management of anemia)

  • Elderly patients (management of hyperphosphatemia)

  • Elderly patients (management of hyperparathyroidism)

  • Pregnant patients

  • Patients with diabetes mellitus (primary prevention)

  • Patients with diabetes mellitus (general principles of management)

  • Patients with diabetes mellitus (team-based care)

  • Patients with diabetes mellitus (self-management programs)

  • Patients with diabetes mellitus (indications for specialist referral)

  • Patients with diabetes mellitus (treatment goals)

  • Patients with diabetes mellitus (glycemic monitoring)

  • Patients with diabetes mellitus (monitoring of renal function)

  • Patients with diabetes mellitus (weight loss)

  • Patients with diabetes mellitus (physical activity)

  • Patients with diabetes mellitus (dietary modifications)

  • Patients with diabetes mellitus (protein intake)

  • Patients with diabetes mellitus (sodium intake)

  • Patients with diabetes mellitus (smoking cessation)

  • Patients with diabetes mellitus (metformin)

  • Patients with diabetes mellitus (RAAS blockers)

  • Patients with diabetes mellitus (beta-blockers)

  • Patients with diabetes mellitus (SGLT-2 inhibitors)

  • Patients with diabetes mellitus (GLP-1 receptor agonists)

  • Patients with diabetes mellitus (statin therapy)

  • Patients with diabetes mellitus (antiplatelet therapy)

  • Patients with diabetes mellitus (RRT)

  • Patients with diabetes mellitus (kidney transplantation)

  • Patients with CVD

  • Patients with osteoporosis (bisphosphonates)

  • Patients with osteoporosis (monitoring)

  • Patients with cancer

  • Patients with HCV infection (liver testing)

  • Patients with HCV infection (screening for other infections)

  • Patients with HCV infection (antiviral regimens)

  • Patients with HCV infection (management of glomerular disease)

  • Patients with HCV infection (kidney transplantation)

  • Patients with HCV infection (kidney transplant recipients)

  • Patients with HCV infection (follow-up)

  • Patients with HIV infection (monitoring of renal function)

  • Patients with HIV infection (evaluation for kidney disease)

  • Patients with HIV infection (ART)

  • Patients with HIV infection (RAAS blockers)

  • Patients with HIV infection (statins)

  • Patients with HIV infection (aspirin)

  • Patients with HIV infection (BP targets)

  • Patients with HIV infection (corticosteroids)

  • Patients with HIV infection (RRT)

  • Patients with HIV infection (kidney transplantation)

  • Patients with HIV infection (pediatric patients)

9.Patient education

Over-the-counter medicines and supplements
Advise adults with CKD to seek medical or pharmacist advice before using OTC medicines or nutritional protein supplements.
B
Avoid herbal remedies in patients with CKD.
D

10.Preventative measures

Immunizations: as per JSN 2019 guidelines, consider offering pneumococcal and influenza vaccination in patients with CKD.
C

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  • Use of contrast media (iodine-containing)

  • Use of contrast media (gadolinium-containing)

11.Follow-up and surveillance

Indications for specialist referral: refer patients with CKD for specialist evaluation in the following circumstances:
AKI or abrupt sustained fall in GFR
GFR < 30 mL/min/1.73 m²
significant albuminuria with albumin to creatinine ratio ≥ 300 mg/g (≥ 30 mg/mmol) or albumin excretion rate ≥ 300 mg/day, approximately equivalent to protein-to-creatinine ratio ≥ 500 mg/g (≥ 50 mg/mmol) or protein excretion rate ≥ 500 mg/day)
progression of CKD
urinary red cell casts, or RBC > 20/hpf sustained and not readily explained
CKD and hypertension refractory to treatment with ≥ 4 antihypertensive agents
persistent abnormalities of serum potassium
recurrent or extensive nephrolithiasis
hereditary kidney disease
B

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  • Monitoring for disease progression