Guidelines of care for patients with Chronic kidney disease
Changhua Christian Hospital
2010-01-01 revised (2ed)
1. DEFINITION AND STAGE OF CKD
2. EVALUATION AND TREATMENT
3. INDIVIDUALS AT INCREASED RISK OF CHRONIC KIDNEY DISEASE
4. ESTIMATION OF GFR
5. ASSESSMENT OF PROTEINURIA
6. MARKERS OF CHRONIC KIDNEY DISEASE OTHER THAN
PROTEINURIA
7. ASSOCIATION OF LEVEL OF GFR WITH HYPERTENSION
8. ASSOCIATION OF LEVEL OF GFR WITH ANEMIA
9. ASSOCIATION OF LEVEL OF GFR WITH NUTRITIONAL STATUS
10. ASSOCIATION OF LEVEL OF GFR WITH BONE DISEASE AND
DISORDERS OF CALCIUM AND PHOSPHORUS METABOLISM
11. ASSOCIATION OF LEVEL OF GFR WITH NEUROPATHY
12. ASSOCIATION OF LEVEL OF GFR WITH INDICES OF FUNCTIONING
AND WELL-BEING
13. FACTORS ASSOCIATED WITH LOSS OF KIDNEY FUNCTION IN
CHRONIC KIDNEY DISEASE
14. ASSOCIATION OF CHRONIC KIDNEY DISEASE WITH DIABETIC
COMPLICATIONS
15. ASSOCIATION OF CHRONIC KIDNEY DISEASE WITH
CARDIOVASCULAR DISEASE
16. ASSOCIATION OF CHRONIC KIDNEY DISEASE WITH THE USE OF
VACCINES
Reference:
A. NKF DOQI 2002
http://www.kidney.org/professionals/kdoqi/guidelines_ckd/toc.htm
KDOQI update of hemoglobin target : 2007
http://www.kidney.org/professionals/kdoqi/guidelines_anemiaUP/ind
ex.htm
B. KDIGO 2009
http://www.kdigo.org/
Practitioner in a team
Multidisciplinary care
• Family members
• Practice nurse
• Nephrologist
• Renal nurse/nurse practitioner
• Pharmacist
• Dietician
• Spirit coach
• Social worker
GUIDELINE 1. DEFINITION AND STAGE OF CKD
Earlier stages of chronic kidney disease can be detected through routine
laboratory measurements.

CKD established, based on presence of kidney damage and level of
kidney function (glomerular filtration rate), irrespective of diagnosis.
GUIDELINE 2. EVALUATION AND TREATMENT
The evaluation and treatment of patients with chronic kidney disease requires
understanding of separate but related concepts of diagnosis, comorbid
conditions, severity of disease, complications of disease, and risks for loss of
kidney function and cardiovascular disease.


Patients with chronic kidney disease should be evaluated to determine:
o
Diagnosis
o
Comorbid conditions;
o
Severity, assessed by level of kidney function;
o
Complications, related to level of kidney function;
o
Risk for loss of kidney function;
o
Risk for cardiovascular disease.
o
Preparation for kidney failure and kidney replacement therapy;
Review of medications should be performed at all visits for the following:
o
Dosage adjustment based on level of kidney function
o
Detection of potentially adverse effects on kidney function or
complications of chronic kidney disease
o
Detection of drug interactions
o
Therapeutic drug monitoring, if possible.
GUIDELINE 3. INDIVIDUALS AT INCREASED RISK OF CHRONIC KIDNEY
DISEASE
Some individuals without kidney damage and with normal or elevated GFR are
at increased risk for development of chronic kidney disease.

increased risk of developing chronic kidney disease, based on clinical
and sociodemographic factors.
。
Diabetes;
。
Hypertension;
。
Autoimmune diseases;
。
Systemic infections;
。
Exposure to drugs or procedures associated with acute decline in
kidney function;
。
Recovery from acute kidney failure;
。
Age >60 years;
。
Family history of kidney disease;
。
Reduced kidney mass (includes kidney donors and transplant
recipients).

Individuals at increased risk of developing chronic kidney disease
should undergo testing for markers of kidney damage, and to estimate
the level of GFR.

Other conditions that affect the kidneys are:
。Glomerulonephritis
。
inherited diseases, such as polycystic kidney disease,
。
Malformations：vesico-ureteral reflux
。
Obstructions : kidney stones, tumors or an enlarged prostate
gland in men.
。
Repeated urinary infections.
GUIDELINE 4. ESTIMATION OF GFR
The following equations provide useful estimates of GFR:

In adults, the MDRD Study and Cockcroft-Gault equations

The serum creatinine concentration alone should not be used to assess
the level of kidney function.
A 24-hour urine sample provides useful information for:

Estimation of GFR in individuals with exceptional dietary intake
(vegetarian diet, creatine supplements) or muscle mass (amputation,
malnutrition, muscle wasting);

Assessment of diet and nutritional status;

Need to start dialysis.
GUIDELINE 5. ASSESSMENT OF PROTEINURIA
The excretion of specific types of protein, such as albumin or low molecular
weight globulins, depends on the type of kidney disease that is present.
Increased excretion of albumin is a sensitive marker for chronic kidney disease
due to diabetes, glomerular disease, and hypertension.
Guidelines for Adults

Under most circumstances, untimed (“spot”) urine samples should be
used to detect and monitor proteinuria in adults.

First morning specimens are preferred

Patients with a positive dipstick test (1+ more) should undergo
quantitative measurement (protein-to-creatinine ratio or
albumin-to-creatinine ratio) within 3 months.

Patients with two or more positive quantitative tests temporally spaced
by 1 to 2 weeks should be diagnosed as having persistent proteinuria
and undergo further evaluation and management for chronic kidney
disease.
GUIDELINE 6. MARKERS OF CHRONIC KIDNEY DISEASE OTHER THAN
PROTEINURIA
Markers of kidney damage in addition to proteinuria include abnormalities in
the urine sediment and abnormalities on imaging studies.

Urine sediment examination or dipstick for red blood cells and white
blood cells

Imaging studies of the kidneys

several novel urinary markers (such as tubular or low-molecular weight
proteins and specific mononuclear cells)
GUIDELINE 7. ASSOCIATION OF LEVEL OF GFR WITH HYPERTENSION
High blood pressure may develop early during the course of chronic kidney
disease and is associated with adverse outcomes—in particular, faster loss of
kidney function and development of cardiovascular disease.

Treatment of high blood pressure in chronic kidney disease should
include specification of target blood pressure levels, nonpharmacologic
therapy, and specific antihypertensive agents for the prevention of
progression of kidney disease and development of cardiovascular
disease.

Target BP:
130/80 mm-Hg
GUIDELINE 8. ASSOCIATION OF LEVEL OF GFR WITH ANEMIA
Anemia usually develops during the course of chronic kidney disease and may
be associated with adverse outcomes.

Patients with GFR <60 mL/min/1.73 m2 should be evaluated for anemia.
8.1. Identifying Patients and Initiating Evaluation
Diagnosis of anemia: Hb concentrations:

<13.5 g/dL in adult males

<12.0 g/dL in adult females
8.2.: Evaluation Of Anemia In CKD
․ complete blood count (CBC) , differential count
․ Absolute reticulocyte count.
․ Serum ferritin to assess iron stores, Serum transferrin saturation
(TSAT)
8.1. Hemoglobin Target (suggested)
selected Hb target should generally be in the range of 11.0 to 12.0 g/dL.
8.4. Using ESAs
․ hypertension, vascular access occlusion, inadequate dialysis, history of
seizures, or compromised nutritional status are not contraindications
․ Route of administration: favors subcutaneous administration in
non-hemodialysis-CKD patients.
8.5. Using Iron Agents

Serum ferritin >100 ng/mL and TSAT >20%

Route of administration: oral in patients with ND-CKD
8.6: Transfusion Therapy
․ transfusion with red blood cells occasionally is required, in particular in the
setting of acute bleeding.
․ no single Hb concentration justifies or requires transfusion.
GUIDELINE 9. ASSOCIATION OF LEVEL OF GFR WITH NUTRITIONAL
STATUS
Low protein and calorie intake is an important cause of malnutrition in chronic
kidney disease.

Patients with GFR <60 mL/min/1.73 m2 should undergo assessment of
dietary protein and energy

For individuals with CRF (GFR <20 mL/min), panel of markers including
at least one value from each of the following clusters:
。 Serum albumin;
。 Edema-free actual body weight, percent standard (NHANES II)
body weight, or subjective global assessment (SGA)
。 Normalized protein nitrogen appearance (nPNA) or dietary
interviews and diaries. (Evidence and Opinion)"

For individuals with chronic renal failure (GFR <30 mL/min) who are not
undergoing maintenance dialysis, the institution of a planned
low-protein diet providing 0.60 g -0.75 g protein/kg/d may be prescribed.
(Evidence and Opinion).

For individuals with chronic renal failure (GFR <30 mL/min) who are not
undergoing maintenance dialysis is 35 kcal/kg/d for those who are
younger than 60 years old and 30-35kcal/kg/d for individuals who are 60
years of age or older. (Evidence and Opinion)."
GUIDELINE 10. ASSOCIATION OF LEVEL OF GFR WITH BONE DISEASE
AND DISORDERS OF CALCIUM AND PHOSPHORUS METABOLISM
Bone disease and disorders of calcium and phosphorus metabolism develop
during the course of chronic kidney disease.

Patients with GFR <60 mL/min/1.73 m2 should be evaluated for bone
disease and disorders of calcium and phosphorus metabolism.

Frequency of sampling (KDIGO)
• therapeutic decisions be based on trends rather than on a single
laboratory value
• individual values of serum calcium and phosphorus, evaluated together,
be used to guide clinical practice rather than the mathematical construct of
calcium–phosphorus product (Ca-P).
․ In patients with CKD stages 3–5, suggest
– lowering elevated phosphorus levels toward the normal range
– maintaining serum calcium in the normal range
– iPTH levels in the range of approximately two to nine times the upper
normal limit for the assay
․ Hyperphosphatemia : phosphate-binding agents: takes into account CKD
stage, presence of other components of CKD–MBD, concomitant
therapies, and side-effect profile (not graded).
– restricting the dose of calcium-based phosphate binders in the presence
of persistent or recurrent hypercalcemia ,arterial calcification and/or
adynamic bone disease,and/or if serum PTH levels are persistently low
– avoiding the long-term use of aluminum-containing phosphate binders
– limiting dietary phosphate intake
․ Treatment of abnormal PTH level
– treatment with calcitriol or vitamin D analogs
– stop when hypercalcemia and hyperphosphatemia and iPTH < 2 x
– GUIDELINE 11. ASSOCIATION OF LEVEL OF GFR WITH
NEUROPATHY
Neuropathy develops during the course of chronic kidney disease and may
become symptomatic.

Patients with chronic kidney disease should be periodically assessed
for central and peripheral neurologic involvement by eliciting symptoms
and signs during routine office visits or exams.

Specialized laboratory testing for neuropathy in patients with chronic
kidney disease is indicated only in the presence of symptoms.
GUIDELINE 12. ASSOCIATION OF LEVEL OF GFR WITH INDICES OF
FUNCTIONING AND WELL-BEING
Impaired functioning and well-being may be related to sociodemographic
factors, conditions causing chronic kidney disease, complications of kidney
disease, or possibly directly due to reduced GFR.

Patients with GFR <60 mL/min/1.73 m2 should undergo regular
assessment for impairment of functioning and well-being:
o
To establish a baseline and monitor changes in functioning and
well-being over time
o
To assess the effect of interventions on functioning and
well-being.
GUIDELINE 13. FACTORS ASSOCIATED WITH LOSS OF KIDNEY
FUNCTION IN CHRONIC KIDNEY DISEASE
The level of kidney function tends to decline progressively over time in most
patients with chronic kidney diseases.


The rate of GFR decline should be assessed to:
o
Predict the interval until the onset of kidney failure;
o
Assess the effect of interventions to slow the GFR decline.
Among patients with chronic kidney disease, the rate of GFR decline
should be estimated by:
o
Computing the GFR decline from past and ongoing
measurements of serum creatinine

Interventions to slow the progression of kidney disease include:
1. Strict glucose control in diabetes;
2. Strict blood pressure control;
3. Angiotensin-converting enzyme inhibition or angiotensin-2
receptor blockade.
4. Quit smoking
o
Interventions that have been studied, but the results are
inconclusive, include:
1. Dietary protein restriction;
2. Lipid-lowering therapy;
3. Partial correction of anemia.

Attempts should be made to prevent and correct acute decline in GFR.
Frequent causes of acute decline in GFR include:
o
Volume depletion;
o
Intravenous radiographic contrast;
o
Selected antimicrobial agents (for example, aminoglycosides
and amphotericin B);
o
Nonsteroidal anti-inflammatory agents, including
cyclo-oxygenase type 2 inhibitors;
o
Angiotensin-converting enzyme inhibition and angiotensin-2
receptor blockers;
o
Cyclosporine and tacrolimus;
o
Obstruction of the urinary tract.
 Monitoring of serum hyperkalemia after initiation of ACEI / ARB
Measure serum K Within 1-3 months after initiation or incretion of dose
GUIDELINE 14. ASSOCIATION OF CHRONIC KIDNEY DISEASE WITH
DIABETIC COMPLICATIONS
The risk of cardiovascular disease, retinopathy, and other diabetic
complications is higher in patients with diabetic kidney disease than in diabetic
patients without kidney disease.

Prevention, detection, evaluation, and treatment of diabetic
complications.

Guidelines regarding angiotensin-converting enzyme inhibitors or
angiotensin-receptor blockers and strict blood pressure control are
particularly important since these agents may prevent or delay some of
the adverse outcomes of both kidney and cardiovascular disease.
GUIDELINE 15. ASSOCIATION OF CHRONIC KIDNEY DISEASE WITH
CARDIOVASCULAR DISEASE
Patients with chronic kidney disease, irrespective of diagnosis, are at
increased risk of cardiovascular disease (CVD), including coronary heart
disease, cerebrovascular disease, peripheral vascular disease, and heart
failure.

All patients with chronic kidney disease should be considered in the
“highest risk” group for cardiovascular disease, irrespective of levels of
traditional CVD risk factors.

All patients with chronic kidney disease should undergo assessment of
CVD risk factors, including:
o
Measurement of “traditional” CVD risk factors in all patients;
o
Individual decision-making regarding measurement of selected
“CKD-related” CVD risk factors in some patients.
․ In patients with CKD stages 3–5D, suggest
–
lateral abdominal radiograph to detect vascular calcification
–
echocardiogram to detect the valvular calcification, alternatives to
computed tomography based imaging
․ Risk factor for CAD
Traditional : sex, age, DM, HTN, hyperlipidemia, smoking, hyperuricemia
CKD related : mineral bone disease, anemia, Homocysteinemia,
malnutrition, inflammation, oxidative stress, endothelial
dysfunction
․ Hyperlipidemia
For adults with Stage 1-4 CKD keep total cholesterol and triglycerides <
200 mg/dL (as national health policy)
GUIDELINE 16. ASSOCIATION OF CHRONIC KIDNEY
DISEASE WITH THE USE OF VACCINES
In patients with renal disease, infection remains among the common causes of
morbidity and mortality. Alterations in the function of the immune system, as
well as unique exposures of this patient population, account for the increased
risk. Vaccination is a valuable tool in preventing many infectious diseases.

Vaccination suggested (opinion)
Influenza
pneumococcus