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CKD -NICE guidance on management (Summary )

NICE has produced extensive guidance on information and this applies to both primary and secondary care.

In the primary care setting along with explanations it may also be helpful to provide written information about CKD , please see section links for helpful patient information resources offer education and information based on stage / severity , cause , complications and the risk of progression NICE recommends developing education programmes and has provided with a list of suggested topics
 Lifestyle – encourage exercise , healthy weight & smoking cessation
 NICE does not recommend low protein diet advice to adults with CKD
 Dietary interventions – consider a referral to dietitian , we have also provided some links which you may find helpful
 Self management -inform about the diagnosis of CKD , shared decision making , support self management → to be able to make informed choices.

 

Risk assessment -Risk assessment for renal replacement therapy using a calculator – the calculator advocated by NICE is the 4-variable Kidney Failure Risk Equation As the name indicates this equation uses the 4 variables namely age , sex , urine to albumin creatinine ratio and estimated eGFR in CKD patients to predict the risk of end stage renal failure ie if the patient is likely to need dialysis within 2-5 yrs.

 

Variable Kidney Failure Risk Equation the risk of needing renal replacement therapy
 in 5 yrs is greater than 5 % using the above calculator

 

ACR ratio -ACR of 70 mg/mmol or more other than cases where this is secondary to diabetes and is being already treated appropriately ACR of > 30 mg /mmol + haematuria

 

eGFR-a consistent fall in eGFR of 25 % or more or a change in eGFR category within 12 months sustained decrease in eGFR of 15 or more per year.

 

Rare or genetic causes of CKD -in the US about 10 % of adults and nearly all children who progress to ESRF have an inherited kidney disease ( IKD ) more than 150 disorders can be categorized under rare kidney disease and they have an overall prevalence of about 60-80 cases
per 100 000 in Europe & the USA.

 

Suspected renal artery stenosis -this is a major cause of hypertension
○ often a result of atherosclerosis or fibromuscular dysplasia
○ fibromuscular dysplasia predominantly affects women
 consider renal artery stenosis in the following situations
 severe treatment resistant hypertension young onset hypertension with negative family history abrupt onset < 50 ( likely fibromuscular dysplasia ) whereas abrupt onset after age 50 is more likely due to atherosclerosis ) peripheral vascular disease sudden deterioration in BP control in some one who had long standing good control and is compliant with medications renal impairment with lack of evidence of an alternative cause for e.g minimal proteinuria recurrent episodes of flash pulmonary oedema and/or refractory heart failure US- renal asymmetry , unilateral small kidney unexplained hypokalemia

 

Urology -CKD and renal outflow obstruction -refer urology unless urgent treatment is needed when the presentation is for example with hyperkalaemia , severe uraemia , acidosis or fluid overload

 

offer an ARB /ACE titrated to highest licensed & maximum tolerated dose

 offer an SGLT2 inhibitor in addition to an ARB or an ACE at an optimised dose monitor for volume depletion and eGFR decline beware of the MHRA caution of canagliflazocin and the increased risk of lower limb amputation
○ monitor if they have risk factors for amputation as poor diabetes control , problems with the heart & blood vessels
○ the guidance suggests to consider stopping canagliflozin if the patient develops foot complications as infection , slin ulcers , osteomyelitis or gangrene advise all patients on SGLT2i’s the importance of routine preventative foot care and adequate hydration please also look at the MHRA adice on SGLT2s and DKA -find this under links. do not offer both ARB and an ACEi in combination ( ie both together ) to adults with CKD advice about the optimum tolerated dose and why it is important to monitor eGFR & potassium check potassium and estimated eGFR before commencing treatment and repeat these between 1-2 weeks after starting treatment and then after each dose increase if the pre-treatment potassium is > 5.0 mmol/L – do not routinely offer ARB/ACEi if the potassium is raised and you are not able to prescribe ACEi / ARB- assess to find the other factors that promote hyperkalaemia and re-check K+ conc take into account that if they are also taking other medications which promote hyperkalaemia alongside ACEi /ARB – more frequent monitoring may be needed stop treatment if K+ level increases to 6.0 mmol/L & other medications known to cause hyperkalaemia have been discontinued once ACEi /ARB have been started do not change dose if
○ eGFR decrease from pre-treatment baseline levels is less than 25 % ( ie the guidance is telling us that a change in eGFR may happen but if we increase the dose and eGFR has dropped by > 25 %- this can be detrimental and you should not titrate the dose upwards )
○ the serum creatinine increases from baseline – but this increase is less than 30 % ( same principle as above ie if the creatinine has increases since the pre-treatment level and we increase the dose upwards- this can be detrimental ) continuing with above aspects of the guidance

REFERENCES

  1. Chronic kidney disease: assessment and management NICE Guideline NG23 August 2021 Recommendations | Chronic kidney disease: assessment and management | Guidance | NICE
  2. McLaughlin KJardine A GMoss J GRenal artery stenosis doi:10.1136/bmj.320.7242.1124
  3. Bokhari MR, Bokhari SRA. Renal Artery Stenosis. [Updated 2021 Jul 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430718/
  4. Devuyst, Olivier et al. “Rare inherited kidney diseases: challenges, opportunities, and perspectives.” Lancet (London, England) vol. 383,9931 (2014): 1844-59. doi:10.1016/S0140-6736(14)60659-0

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