Chronic Kidney Disease Pathway Document Description Presented ...

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Urinalysis Protein No diabetes Proteinuria is a significant risk factor for progression in renal disease and for cardiovascular morbidity and mortality. Unlike haematuria, proteinuria almost always has a renal origin. Management should include assessment of: • Albumin/creatinine ratio (ACR) / Protein/creatinine ratio (PCR) • Haematuria • Serum creatinine and eGFR To detect and identify proteinuria, use ACR in preference, as it has greater sensitivity than PCR for low levels of proteinuria. For quantification and monitoring of proteinuria, PCR can be used as an alternative. ACR is the recommended method for people with diabetes. http://www.nice.org.uk/nicemedia/pdf/CG073QuickRefGuide.pdf Urine should be tested for protein annually in stage 3, and 6 monthly in stages 4 and 5 if stable. If protein is detected, exclude infection (only if symptoms suggest) and retest. Measurements should not be made during acute illness. Send an early morning urine specimen for microalbumin and ACR level. Persistent proteinuria is defined as 2 or more positive tests, ACR > 30 spaced by 1-2 weeks. A positive ACR test (>30) in the presence of hypertension indicates initiation of an ACE inhibitor http://www.nice.org.uk/nicemedia/pdf/CG073QuickRefGuide.pdf However, patients with CKD have an increased risk of CVD mortality. Consideration should be given to initiating ACE inhibitors in patients with CKD, positive microalbumin (< 30mg/day) and increased CVD risk, due to their cardioprotective effect. http://www.sign.ac.uk/pdf/sign103.pdf 40
Recommendation: Therefore consider ACE inhibitor therapy regardless of established proteinuria for patients with CKD and: • Hypertension • Heart failure • Coronary, cerebral or peripheral vascular disease • Diabetes mellitus • Multi-system disease including SLE, rheumatoid arthritis, vasculitis For many in this patient group, the cardiovascular impact of their renal disease is more significant than the risk of continuing to end stage renal failure. http://renux.dmed.ed.ac.uk/edren/Unitbits/CKDmanagement.html see initiation of ACE/ARB Protein/creatinine ratio PCR PCR is the best test to confirm clinical proteinuria at higher levels. ACR at higher levels (> 45) may be inaccurate. If using PCR, then proteinuria is defined as Positive results: PCR > 50 In 2 separate specimens spaced by 1-2 weeks. http://www.nice.org.uk/nicemedia/pdf/CG073QuickRefGuide.pdf ACR >70 (PCR 70 (PCR >100) • Refer to nephrologist. 41
Page 1 and 2: Chronic Kidney Disease Pathway Docu
Page 3 and 4: Pathway for the Identification and
Page 5 and 6: Contents Introduction …………
Page 7 and 8: Introduction Chronic kidney disease
Page 9 and 10: CKD Pathway D I A G N O S I S Ensur
Page 11 and 12: Kidney function deteriorates natura
Page 13 and 14: Joint Speciality Committee - Royal
Page 15 and 16: Acute Renal Failure Acute Renal Fai
Page 17 and 18: Next Steps Any patient suspected to
Page 19 and 20: Return to overview CKD Stages CKD S
Page 21 and 22: Practice Action Plan Compiling a Ch
Page 23 and 24: Action Rationale Responsible Run a
Page 25 and 26: eGFR
Page 27 and 28: CKD Stages CKD Stage Description Re
Page 29 and 30: References Joint Speciality Committ
Page 31 and 32: Cardiovascular Risk All patients wi
Page 33 and 34: Hypertension Blood pressure should
Page 35 and 36: Further information on the pharmaco
Page 37 and 38: Irbesartan* Valsartan Losartan* *Sp
Page 39: • Diuretics • Lithium carbonate
Page 43 and 44: Lower levels of proteinuria should
Page 45 and 46: Glycaemic Control CKD and Diabetes
Page 47 and 48: References Audit Commission (2002)
Page 49 and 50: Influenza and Pneumococcal Vaccine
Page 51 and 52: Stage 3 Management at stage 3 shoul
Page 53 and 54: If all other causes for the anaemia
Page 55 and 56: Clinic inclusion criteria: Patients
Page 57 and 58: Where vitamin D supplementation is
Page 59 and 60: Stage 5 Patients identified at CKD
Page 61 and 62: Information to include with referra
Page 63 and 64: Appendix 1 The Dudley Group of Hosp

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