Camden Chronic Kidney Disease Pathway

Renal Function (eGFR) should be measured

Persistent ACR >3.5 / PCR >15 ACR 30 / PCR 50 ACR 70 / PCR 100 ACR >250 / PCR >300 annually in all patients with
Test Urine Diabetes, Hypertension, Cardiovascular
proteinuria >1+
Microalbuminuria If hypertensive BP control - ACEi/ARB Nephrotic range Disease and Heart Failure
Check spot urine for consider ACEi/ARB Refer Urgent Referral
ACR (or PCR) Other groups at risk: Acute Kidney Injury
Afro-Caribbean & South Asian populations
Structural renal tract disease, kidney stones or eGFR is unreliable in AKI so
eGFR > 60 CKD 1 or eGFR 45 – 59 eGFR 30 - 44 eGFR 15 – 29 prostatic hypertrophy review of sudden deterioration in
eGFR <15
2 CKD 3A CKD 3B CKD 4 Multisystem diseases with potential kidney serum creatinine should be used to
CKD 5
Check eGFR involvement eg SLE identify AKI
eGFR >60 normal unless Moderate decrease in GFR, with or without Severe decrease in Family history or hereditary kidney disease
Established renal
evidence of kidney disease other evidence of kidney damage GFR +/- other evidence Patients on long term nephrotoxic drug eg Review all previous results to
failure
(structural abnormality If new, confirm with repeat within 2 weeks of kidney damage Lithium, NSAIDS determine rate of decline
and/or proteinuria and/or Creat >1.5x baseline
proteinuria + haematuria) Renal Ultrasound for:
Progressive CKD
Other Blood Pressure, Creatinine and eGFR, Hb, Urine Protein Creatinine Ratio (PCR) (eGFR falls > 5 within 1 yr Repeat
Investigations or > 10 within 5 yrs) within 5 days
+ Potassium, Calcium , Phosphate

+ Bicarbonate, Vitamin D, PTH Visible or persistent invisible haematuria Creat >2x baseline

Urinary sepsis, Lower Urinary Tract Symptoms

Every 12 months 6 monthly 3 monthly Refer acute
Family history of polycystic kidney disease medicine
(Aged over 20)
Creat >3x baseline
Management in Primary Care Blood Pressure control Stage 4 or 5 CKD
Monitor BP at least annually Refer RFH
Management Treat modifiable risk factors Target < 140/90 (non-diabetics) renal unit
or < 130/80 (urine PCR >100 or diabetic ) Reasons for Referral
Lifestyle advice AKI phone
Smoking, weight, exercise, salt & If urine ACR >30 or PCR >50 or if diabetic with CKD 4 & 5 CICS Referral 07908422116
alcohol intake microalbuminuria: ACEI or ARB first line Referral or discussion advised even if dialysis may
(avoid if K+ >5 mmol/L) not be appropriate in conjunction with secondary Information needed on referral
Stop nephrotoxic drugs care. Discuss prior to referral where elderly/frail/
Check Creatinine, K+: Before start, after 2 weeks & terminal illness & stable CKD/BP/Hb. General medical history
Blood Pressure Control after each dose change
If Creatinine increases by >30% or GFR falls by Isolated proteinuria / PCR > 100 Urinary symptoms
Influenza & Pneumococcus >25%, Repeat with K+ and seek advice Or PCR >45 and microscopic haematuria
immunisation Medication (dates of starting and
Macroscopic haematuria stopping ACEI/ARB if applicable)
Assess Cardiovascular Risk Hyperkalaemia Urgent referral
Mineral metabolism (after negative urological evaluation)
Consider Statin, Aspirin is disturbed in most Examination e.g. BP, oedema,
If K+ > 6 mmol/L Acute Kidney Injury
patients with CKD4/5: Progressive fall in eGFR bladder
Cardiovascular Risk Check no haemolysis (Acute renal failure)
(>15 mL/min over 12 months)
CKD is a powerful risk factor for
25 OH Vit D: Urine dipstick for blood and protein
cardiovascular disease Check diet (Bananas, Malignant hypertension
If less than 75 nmol/l Fall of eGFR of 25% during first 2 months on
Statins: Secondary prevention: all soft fruit, fruit juice,
Calceos / Adcal D3 2 tabs ACEI / ARB Urine culture and PCR
with established vascular disease: chocolate) Hyperkalaemia
daily or cholecalciferol (if protein present)
MI, angina, stroke, Heart Failure due (K+ > 7 mmol/L)
20,000 iu weekly Uncontrolled Hypertension
to CHD, diabetics >40 yrs. Primary Stop NSAIDs and
(BP > 150/90 on 3 agents) FBC, Creatinine & eGFR, Urea, Na+,
prevention: if 10yr CVD risk >20% LoSalt, Stop K+ Nephrotic syndrome
K+, Albumin, Calcium, Phosphate,
Aspirin: Secondary prevention: All retaining diuretics
Anaemia (after exclusion of other causes) Cholesterol, HbA1c (in diabetes)
with established vascular disease ,
Where Hb ≤ 11 or if symptomatic
Primary prevention: Consider if 10yr Stop ACEI/ARB if
List all old Creatinine results (as well
CVD risk >20% hyperkalaemia persists
Persistently abnormal serum K+, Ca2+, PO4 as any eGFR reports) with dates
References
This pathway based on the North Central London CKD Guide 2011 Suspected renal artery stenosis, rare or genetic Result of renal ultrasound if available. V2.2 Links updated Feb 16
DOH 2005 - NSF for renal disease Pathway created by Alex Warner July 2012
RCP National Collaborating Centre for Chronic Conditions - CKD Guidance causes or underlying systemic illness, Reviewed by Alex Warner Sept 2015
The Renal Association - UK CKD Guidelines e.g. SLE, vasculitis, myeloma Review due Sept 2018
Clinical contact for this pathway: Dr John Connolly johnconnolly@nhs.net
Comments & enquires relating to medication: NHS Camden Medicines Management Team mmt.camdenccg@nhs.net
Refer to current BNF or SPC for full medicines information