How to Treat Patients

Primary care practitioners have a key lifesaving role in detecting Chronic Kidney Disease (CKD), a silent killer.

One in nine adult Americans have Chronic Kidney Disease. CKD is a known risk factor for Cardiovascular disease (CVD). Most patients with CKD die from CVD before they develop kidney failure.

IDENTIFYING KIDNEY DISEASE PROTECTS THE HEART 

 ASSESS/SCREEN ALL PATIENTS WITH CKD RISK FACTORS (HTN, CVD, DM, FHX OF CKD, AGE>60, NEPHROTOXIC DRUG EXPOSURE,

 -- NSAIDS, US ETHNIC MINORITY) FOR CKD WITH THE FOLLOWING TESTS:

• Blood Pressure Measurement
• eGFR(estimated GFR) from serum creatinine using MDRD prediction equation2
• Urine Dipstick
• Urine Microalbumin

Note: 24-hour urine collections are not needed

EVALUATE ALL CKD PATIENTS FOR CKD COMPLICATIONS:

• CVD, HTN, Proteinuria, Volume overload- may be present at any eGFR
• Anemia, Metabolic Bone Disease, Acidosis, Hyperkalemia, Malnutrition,

Neuropathy- often develop once eGFR less than 60ml/min/1.73m2

Screen for CKD complications
Anemia
Metabolic Bone Disease
Acidosis
Hyperkalemia
Malnutrition

Blood Tests
Hgb Ca/PO4
Intact PTH
25&1,25(OH)VitD
Bicarbonate
Potassium
Albumin 

TREAT CKD-ASSOCIATED ABNORMALITIES TO BOTH OPTIMIZE CARDIOVASCULAR STATUS AND

TO SLOW CKD PROGRESSION AND KIDNEY FAILURE PREVENTION:

Cardiovascular Risk Factors ASSOCIATED WITH CKD

• HTN ACEI/ARB/ BP<130/80/Less than 2000 mg of sodium
DM HbA1C<7.0

Hyperlipidemia Statin LDL<100

Microalbuminuria ACEI/ARB

• Proteinuria ACEI/ARB/ Avoid High Protein Diet

• Volume Overload Diuretics/Diet

• Lifestyle.. Smoking Cessation/Exercise/ Target Ideal Body Weight

Also all patients should receive CKD education including how to avoid nephrotoxins (i.e. NSAIDS)

Consultation with a nephrologist should be considered:

 GFR<30ml/min/1.73m2(stage 4) refer for RRT preparation & transplant evaluation
 Rapid progression (loss of GFR>4 ml/min/1.73m2 per year)
 Diagnosis is unclear
 Co-managing of CKD complications
 Proteinuria >1g per day
 Difficulty controlling BP


• CKD IS DEFINED as either GFR<60ml/min/1.73m2 or kidney damage or for 3 months or longer.
o Kidney damage is defined as pathological abnormalities or markers of damage, including abnormalities in blood or urine tests (proteinuria/hematuria) or imaging studies.

• eGFR (estimated Glomerular Filtration Rate) is the best method currently available of assessing total kidney function for most patients. It is useful as a screening test for CKD. eGFR can be calculated using the MDRD (Modification of diet in renal disease) prediction equation, which factors in the serum creatinine value, age, gender, race and is normalized to average adult surface area of 1.73m2. http://www.kidney.org/professionals/kdoqi/gfr_calculator.cfm

• PROTEINURIA is the most common marker of kidney damage. A routine urine dipstick detects albumin, the predominant protein excreted by the kidney in most types of renal disease. It is not sensitive enough to detect microalbuminuria, which is a small amount of albumin, not smaller molecules. Microalbuminuria (i.e., excretion of 30 to 300 mg of albumin per 24 hours) is albumin excretion above the normal range but below the level of detection by tests for total protein (urine protein dipstick).

Screenings for microalbuminuria can be performed using microalbumin-sensitive dipstick or a random urine sample analysis where microalbumin results are expressed as Microalbumin/Creatinine ratio (mcg albumin/mg creatinine) to adjust for urine concentration. The ratio estimates a 24-hour albumin excretion in the urine. Therefore, a 24-hour urine collection usually is not necessary.

A spot albumin to creatinine ratio of 200mcg/mg creat is equivalent to 200 mg of albumin in a 24-hour urine collection (microalbuminuria by definition). Macroalbuminuria or albuminuria refers to excretion of more than 300 mg of albumin per 24 hours, which is equivalent of albumin/creatinine ratio of 300mcg/mg crea.

• Classification of CKD by Severity:

Stage
ICD-9-CM Code
Description
GFR
(mL/min/1.73m2)
Clinical Presentation*
 

Stage 1

585.1 CKD

Kidney damage with normal or GFR/>90  
Markers of damage (Hematuria, proteinuria, HTN) Dx & Tx,
Tx of comorbid conditions
Slowing progression,
CVD risk reduction

Stage 2

585.2 CKD

Kidney damage with mild  GFR  60/89
Mild complications
Monitoring progression with eGFR, microalbuminuria, proteinuria

Stage 3

585.3 CKD

Moderate  GFR/30-59
Moderate complications
Evaluating & treating complications. Nephrology consultation may be beneficial

Stage 4
585.4 CKD

Severe/ GFR 15-29
Severe complications Nephrology referral for
preparation for kidney replacement therapy 

 Stage 5- End Stage Renal Disease
585.6 ESRD

Kidney failure <15  (or dialysis)
Uremia, CVD
Replacement (if uremia present)

Leanna B. Tyshler, MD
Chronic Kidney Disease Medical Advisor
Northwest Kidney Centers
Ph: 206.292.2771, ext. 3086

Email: tyshlerl@nwkidney.org

Adopted from National Kidney Foundation. K/DOQI Clinical Practice Guidelines for CKD, 2002

*Includes presentations and actions from proceeding stages.
Sarnak, MJ, et al. Kidney Disease as a Risk factor for Development of CVD.