Chronic Kidney Disease

Identifcation, Evaluation and Management of Patients

Effective Date: etee etee
Scope
The fst at of this guideline ovides ecoendations fo the investigation and evaluation of adult
atients (9+) at isk fo chonic kidney disease (CKD). The second at of this guideline focuses on
the anageent of adult atients with known CKD and includes cae ojectives and atient self-
anageent.
ecialized anageent of estalished CKD e.g. eythooietic agents fo aneia enal elaceent
theay and teatent of calciu hoshate o aathyoid hoone (PTH) anoalities is eyond
the scoe of this guideline.
Diagnostic Code: (chonic enal failue)
Part 1: Identifcation and Evaluation of Patients at Risk for CKD
This section coves:
I. Pevention and isk factos
II. Investigation
III. Diagnosis and staging of CKD
IV. Deteining the cause of CKD
V. Evaluating atients with anoal sceening tests
VI. Flow diaga fo evaluating and anaging susected CKD
I. Prevention and risk factors
Identify atients at isk fo CKD ased uon a diected edical and sugical histoy including co-
oidities (e.g. diaetes cadiovascula disease [CVD]) and dietay social deogahic and
cultual factos a eview of sytos and hysical exaination. Poulations at inceased isk
include those with:
Diaetes
Hyetension with o without CVD
A faily histoy of kidney disease
ecifc high-isk ethnic gous: Fist Nations Pacifc Islandes Afican descent and Asians
Note: Age > 6 yeas is associated with an inceased isk of iaied kidney function ut evidence is
insuffcient to ecoend sceening solely on the asis of age.
II. Investigation
It is ecoended that hysicians sceen at-isk oulations evey - yeas deending uon
clinical cicustances (e.g. yealy fo esons with diaetes) using seu ceatinine and ando
uine tests (acoscoic/icoscoic uinalysis and ACR). Estiated gloeula fltation ate
BRITISH
COLUMBIA
MEDICAL
ASSOCIATION
CHRONlC KlDNEY DlSEASE lDENTlFlCATlON, EvALUATlON AND MANAGEMENT OF PATlENTS
2
Diagnostic Code:
(eGFR) is the est ake fo CKD and is couted fo the seu ceatinine. Most las in
Bitish Coluia (BC) autoatically eot eGFR when a seu ceatinine is odeed. (ee
Aendix B fo futhe infoation on eGFR calculations.)
Investigational tests
a) eu testing: eGFR values:
< 6 L/in and persistent (esent fo > 3 onths) indicates sustantial eduction in kidney
function.
> 6 L/in and < L/in in the asence of uine anoalities o stuctual
anoalities on iaging studies (e.g. ultasound) does not indicate kidney disease.
Age > 7 yeas: accuacy of eGFR fo atients ove 7 is questionale and ay
undeestiate tue kidney function. Values of eGFR < 4 should e consideed as a likely
indicato of deceased enal function and eit futhe wok-u. Values etween
4 and 6 ay efect noal vaiation in the asence of othe conditions howeve caution is
still ecoended with esect to edications dye and isk of acute kidney injuy with sevee
illnesses. Coelation with clinical condition is ecoended.

Age > yeas: equation fo eGFR is oleatic and isk of ogession of CKD is
not known. In the asence of othe etaolic o heatological anoalities a consevative
aoach is ecoended. Values etween 4 and 6 ay efect noal vaiation
in the asence of othe conditions. Caution is still ecoended with esect to
edications dye and isk of acute kidney injuy with sevee illnesses.
Estiates ased on seu ceatinine easueents (eGFR) ay e uneliale in atients with
vey lage o sall ody haitus those on secifc diets (vey high o vey low otein) and in
atients eceiving edications that intefee with the excetion of ceatinine (e.g. tiethoi
and sulfaethoxazole ciofoxacin fenofate).
Execise diet and/o hydation status ay affect kidney function estiates o the degee
of aluinuia/oteinuia. If aseline tests ae anoal o susequent tests ae signifcantly
diffeent fo aseline confation y eeat testing is waanted.
) Uine testing: acoscoic/icoscoic analysis and aluin/ceatinine atio (ACR) values
Rando uine tests fo acoscoic/icoscoic uinalysis and ACR:
ignifcant anoalities: esistent white lood cells o ed lood cells in the asence
of infection o instuentation; esence of any cellula casts is always athological.
ACR elevation (> . g/ol ales; > . g/ol feales) on out of 3 seial tests
efoed week to onths aat indicates ico-vascula disease +/- gloeula
disease.
Uine test anoalities even with esistent eGFR values 6 l/in indicate anoal
kidney function eithe as an isolated condition o as a syto of a systeic disease.
4-hou uine collections ae not necessay in ost cases.
ACR is the ethod that allows one to test fo aluin esent in quantities aove noal
ut elow the detectale ange on standad disticks. In the ast the wod icoaluin
has een used ut this ay lead to a false iession that thee is a diffeent olecule
when thee is not. Thus ACR is the efeed ethod y which to assess anoal
levels of aluin. Note that this guideline uses the thesholds adoted y the Canadian
Diaetes Association fo the detection of icoaluinuia. As ethods iove and
futhe data ecoes availale these cutoffs ay e evised. eial ACR tests can noally
e incooated into the outine visit schedule.
CHRONlC KlDNEY DlSEASE lDENTlFlCATlON, EvALUATlON AND MANAGEMENT OF PATlENTS
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Diagnostic Code:
Stage Description

1 Kidneydamage
b
withnormalor eGFR
2 Kidneydamage
b
withmild eGFR
3 Moderate ineGFR
4 Severe ineGFR
5 Kidneyfailure
Acting on test esults
Noal: eeat annually o as clinically indicated and onito lood essue.
Anoal: conf and evaluate (Tale elow).
III. Diagnosis and staging of CKD
CKD is defned as eGFR < 6 L/in fo > 3 onths o evidence of kidney daage (athologic
anoalities o akes of daage including anoalities in lood o uine tests o iaging
studies). If CKD is esent deteine its stage ased on eGFR uinalysis and ACR. The following
staging syste designed y the U National Kidney Foundation with intenational inut is
ecoended to facilitate assessent and anageent of CKD.
3
Table 1. Stages of CKD
PotentialComplicationsofreducedeGFR
a
(alphabetically)

Anemia,includingfunctionalirondefciency
BPincreases
Calciumabsorptiondecreases
Dyslipidemia/heartfailure/volumeoverload
Hyperkalemia
Hyperparathyroidism
Hyperphosphatemia
Leftventricularhypertrophy
Metabolicacidosis
Malnutritionpotential(late)
NOTE:
a
The listed colications ae not secifc to CKD ut tend to occu with inceasing fequency and ae oe diectly
attiutale to CKD at lowe eGFR (e.g. stages 4 and ). If colications ae noted at an ealy stage of CKD
investigation of altenative causes is ecoended e.g. ofound aneia at eGFR of l/in is likely not
attiutale to low kidney function alone.

Kidney daage is defned as athological anoalities (kidney iosy esults) o akes of daage including
anoalities in lood o uine tests (otein/aluin in the uine ed lood cells white lood cells o casts) o iaging
studies.

IV. Determining the cause of CKD
Iaied kidney function is often ulti-factoial. If ossile deteine a iay cause of
kidney disease in all atients. Kidney ultasound is a useful exaination to identify olycystic
kidney disease cance stones and ostuction. Disceancy in kidney size ay signal clinically
signifcant enal atey stenosis (the wok u fo enal atey stenosis is eyond the scoe of this
guideline).
Even if a iay cause sees ovious (e.g. hyetension diaetes) the ossiility of a seious
undelying disode (e.g. vasculitis systeic luus eytheatosis) ust e consideed in atients
with:
Anoal uinalysis e.g. oteinuia heatuia cellula casts o coinations theeof.
Raid sustained decline in kidney function (eGFR > -%/yea) desite eedy of
evesile eciitants e.g. volue contaction feile illness edications.
Consistent iaient of kidney function in the asence of isk factos.
Constitutional sytos suggesting systeic illness.
udden o sevee onset of sytos e.g. edea unelated to heat o live disease.

eGFR
a
90
60-89
30-59
15-29
<15or
ondialysis
CHRONlC KlDNEY DlSEASE lDENTlFlCATlON, EvALUATlON AND MANAGEMENT OF PATlENTS
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Diagnostic Code:
Refe to an intenist o nehologist fo futhe evaluation if an etiology cannot e deteined.
Note that occasionally a sceening test will identify a seious systeic disease o ealy stages
of an acute illness. In atients with active uine sedients (c casts o cellula casts otein)
constitutional sytos o unexlained seveity of kidney dysfunction ot consultation with a
secialist and/o e-evaluation of tests is indicated.
V. Evaluating patients with abnormal screening tests
Patient anageent should efect CKD stage and eGFR uinalysis and ACR esults (see Tale ).
Table 2. Evaluating patients with abnormal screening tests Evaluating patients with abnormal screening tests
a
Stage OtherResults Recommendations
b
Stage1or2;eGFR
60mL/min
plusevidenceof
kidneydamage
c
Stage3;eGFR=
30-59mL/min
Stage4;eGFR=
15-29mL/min
Stage5;eGFR<
15-mL/min
Urinalysisnormalbut
ACRequivocal(2-20
male;2.8-28female)
onatleast2outof3
occasions
Urinalysisabnormalor
ACRabnormal
(>20male;
>28female)
Urinalysisnormal
butACRequivocal
(2-20male;2.8-28
female)
Urinalysisabnormalor
ACRabnormal
(>20male;
>28female)
Regardlessofother
results
Regardlessofother
results
DeterminecauseofCKD.
SeemanagementadviceinPart2.
ConsiderkidneyU/S.
d
Orderannualcreatinineandurinetests.
Considerreferraltonephrologist/internist
e
ifurineproteinis
increasing,eGFRisdeclining>10%annually,orserumK
+
is
repeatedly>6.0mmol/L.
SeemanagementadviceinPart2.
ConsiderkidneyU/S.
Considerreferraltonephrologist/internist.
Considerreferraltourologistforisolatedmicrohematuriaeven
ifU/Sisnormal.
SeemanagementadviceinPart2.
ConsiderkidneyU/S.
Orderannualcreatinineandurinetestsq6months.
Considerreferraltonephrologist/internistifurineprotein
increasingoreGFRdeclining>10%/year.
SeemanagementadviceinPart2.
OrderkidneyU/S.
Considerreferraltonephrologist/internist.
SeemanagementadviceinPart2.
Refertonephrologist/internist.
SeemanagementadviceinPart2.
Referurgentlytonephrologist/internist.
KEY:ACR=albumin/creatinineratio,CKD=chronickidneydisease,CVD=cardiovasculardisease,eGFR=estimatedglomerularfltrationrate,
K=potassium,U/S=ultrasound
NOTE:
a
In the asence of othe systeic illness.

All CKD atients ae at isk fo CVD theefoe the usual otocols fo CVD isk evaluation and teatent
should e followed.
4
c
Patients with eGFR > 6 l/in in the asence of anoalities of uine o iaging tests do not have
tage o CKD. If the atient is in a high-isk oulation eeated sceening is ecoended at egula
intevals.
d
Kidney U/ ay e equied in those with a faily histoy of olycystic kidney disease o sytos of
uinay tact ostuction infection o stones. It can also quickly identify evesile conditions.
e
Intenists ae skilled in the initial woku and anageent of ealy CKD and given the usual concoitant
association of CKD and CVD ae also aoiate as the initial efeal.

CHRONlC KlDNEY DlSEASE lDENTlFlCATlON, EvALUATlON AND MANAGEMENT OF PATlENTS
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Diagnostic Code:
Figure 1. Flow Diagram for Evaluating and Managing Patients with Suspected CKD
Part 2: Management of Patients with Established CKD
This section coves:
I. Identifying cae ojectives and tagets
II. Pactice oints fo goal setting
III. uoting atient self-anageent
IV. Meeting cae ojectives
I. Identifying care objectives and targets
Physicians will ideally identify cae ojectives fo all atients with CKD (see Tale 3). Deending
on the level of kidney function and colexity of theay equied these cae ojectives ay e
oe o less diffcult to achieve without hel fo a secialized tea of health cae ofessionals
including a nehologist. Teatent goals ust e tailoed to the individual.

Identify and screen populations at increased risk
Ascetain the isk factos.
Pefo a systes eview and hysical exa.
Ode laoatoy tests including seu ceatinine/eGFR and ando uine
fo aco/ico uinalysis and ACR (icoaluin).
Reeat tests within 3 onths to conf any anoal esults
unless constitutional sytos ae esent and equie oe ugent
investigation anageent and efeal.
Follow-up tests are abnormal:
Deteine CKD stage ased on
eGFR uinalysis and ACR.
Deteine cause of kidney
disease.
Aange ongoing follow-u (ee
Tale ).
ee cae ojectives in Pat
(ee Tale 3).
Follow-up tests are normal:
Monito annually o as clinically
indicated (ee Tale 3).
CHRONlC KlDNEY DlSEASE lDENTlFlCATlON, EvALUATlON AND MANAGEMENT OF PATlENTS
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Diagnostic Code:
BP<130/80.
ACEI/ARBrecommendedin
additiontootherdrugs.*
Stabilityofkidneyfunctionor
<10-15%declineineGFRannually.
Reduceabnormalvaluesby
50%ormorefrombaseline.
ACEI/ARBsrecommended.*
Reduceriskinthoseathigh
risk.
Lipidtargets(<70yrs):LDL
<2.5;TC/HDLratio<4.0.
A1C:7.0%(0.07).

AdequatenutritionandBMInear
ideal(18.5-24.9).

Completesmokingcessation.
Hgbwithinnormalrangefor
sexifnotonESAtreatment,
Hgb>110-125g/LifonESA
treatment.
Transferrinsaturation>20%.
Calcium2.2-2.5mmol/L.
Phosphorus0.75-1.4mmol/L.
iPTHinnormalrange.
5
Albumininnormalrange.
Preventionofinfuenza.
Preventionofpneumonia.
Seroconversion,preventionof
HepB(seroconversionratehigher
ifimmunizedearly).
6

Avoidanceofaminoglycosides,
NSAIDs,COX-2inhibitors,
intravenousorintra-arterial
radiocontraststudies.
Providingsupport.
Optimizeself-management.
BP
Kidneyfunction
measurements
Urinetesting
Monitorserum
electrolytes
CVDrisk
assessment&
lipidprofles
Diabetes:Blood
glucosecontrol
overtime
Weight&
nutrition
Smoking
Assessmentof
conditions
associatedwith
CKD
Fluvaccine
Pneumococcal
vaccine
Awarenessof
HepatitisBrisk
Limitexposure
tonephro-
toxins/drug
adjustments
Psychosocial
health
Table 3: Care objectives and targets
Care Objective Target
Measureandrecordatdiagnosisandateveryvisitthereafter.SeeBCguideline:
Hypertension Detection, Diagnosis and Managementatwww.BCGuidelines.ca
ObtainregularmeasurementsofserumcreatinineforeGFR(atleastq6months)
andafteranychangeinmedications,medicalintervention,orclinicalstatus.
ACR(microalbumin)every6-12monthsorasclinicallyindicated.
Measureafterchangeinmedications,medicalintervention,orclinicalstatus
withparticularattentiontoK
+
.
CheckserumcreatinineandK
+
priortostartingACEIsandARBs,within2
weeksofstarting,andwithin2weeksafterdoseincrease.
Serumcreatininerise>20%oreGFRdecrease>15%afterdoseincrease
shouldbefollowedbyfurthermeasurementswithin2weeks.
Calculate&recordCVDrisk.
Manageinaccordancewithrelevantguidelines.
Checkfastinglipidsyearlyoncetargetvaluesareachieved&morefrequently
inpatientsonlipidloweringmedication.
MeasureA1Cq3monthsorasclinicallyindicated.SeeDiabetes Care guideline
atwww.BCGuidelines.ca
Long-actingsulfonylureasmaybeassociatedwithhypoglycemiawithunstable
eGFR,especiallythosebelow45.Ifrecurrenthypoglycemia,orunstableeGFR
considerusingshort-actingsulfonylureasornon-sulfonylureas.
InthosewithunstableeGFRoracutechangesinclinicalcondition,metformin
shouldbeheld.
Recordweight&BMIoneachvisitforcomparison.
Encouragepatienttostopsmoking,enquireateveryvisit,supportwhenreceptive.
Measureatleastyearly(morefrequentlywithadvancedCKD):
CBC.
Mineralmetabolism(calcium,phosphorus,iPTH).
Nutritionprofle(albumin).
Immunizeannually.
Immunizeevery10years.
ImmunizationatahigherlevelofeGFRmorelikelytoresultinseroconversion
ifpatientisbeingconsideredforhemodialysis.Screeningandvaccinationin
consultationwithnephrologyteam.
Reduceriskofacuteorchronicdeteriorationofkidneyfunction.
Adjustrenallyexcreteddrugsaccordingtokidneyfunction.
Depressionandgriefreactionmayoccurwithchronicdisease.
Identifyandaddresspsychosocialproblemsthataffecttheillness.
KEY:BP=bloodpressure;A1C=glycatedhemoglobin(previouslyHbA1C);ACEI=angiotensin-convertingenzymeinhibitor;ARB=angiotensinIIreceptorblocker;
ACR=albumin/creatinineratio;BMI,bodymassindex;COX-2=cyclooxygenase-2;ESA=erythropoiesis-stimulatingagent;eGFR=estimatedglomerularfltrationrate;
HDL=high-densitylipoprotein;Hgb=hemoglobin;iPTH=intactparathyroidhormone;LDL=low-densitylipoprotein;NSAID,non-steroidalanti-infammatorydrug;
TC=totalcholesterol.
NOTESFORTABLE3: * ReductionofproteinuriacanbefacilitatedbytheuseofACEI/ARBs.Thishasbeenshowntoreducetherateofprogressionofchronicrenal
insuffciencyinhypertensivepatientswithdiabetesorchronicglomerulonephritis.
7,8
InsevereCKD(eGFR<15ml/min),weightlossmayindicateacatabolicstateandapossibleneedfordialysis.
CHRONlC KlDNEY DlSEASE lDENTlFlCATlON, EvALUATlON AND MANAGEMENT OF PATlENTS
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Diagnostic Code:
II. Practice points for goal setting
When setting goals with you atient conside the following:
Execise diet and/o hydation status ay affect kidney function estiates o the degee
of aluinuia/oteinuia. If aseline tests ae anoal o susequent tests ae signifcantly
diffeent fo aseline conf y eeat testing.
Rigoous contol of BP has een shown to educe the isk of colications and otality ates.
In aticula the inhiition of the enin angiotensin syste with ACE inhiitos o ARBs has
een shown to e vey effective. Diuetics -lockes and/o calciu channel lockes
ay also e equied since ost atients equie oe than two edications to each taget
values.
9
ee BC guideline: Hypertension Detection, Diagnosis and Management.
Evey adult with kidney disease ay e at inceased isk of cadiovascula disease.
4
Nehotoxic edications (e.g. NAIDs COX- inhiitos ainoglycosides) should e avoided
o used with caution in atients with even ild kidney iaient (eGFR 6-9 L/in with
evidence of kidney daage) and kidney function should e onitoed if they ae used.
IV o inta-ateial adiocontast use oses a high isk of acute kidney injuy in atients
with tage 4 o CKD and a odeate isk in atients with tage 3 disease.

If iaging is
equied altenate iaging techniques including MRI angiogahy should e consideed
fo these atients. If no altenative exists and the ocedue is edically necessay the atient
should ovide witten infoed consent and otection with IV hydation and N-acetyl cysteine
ay e used accoding to a ulished otocol o in consultation with nehologists.

Patients with CKD ae at high isk of futhe acute kidney injuy with volue contaction e.g.
nausea voiting diaheal illnesses o the use of cetain owel eaations.
Review edication list identify edications exceted y the kidneys (e.g. etfoin digoxin
and lithiu) and adjust dosages as aoiate o use altenate teatent.
3
(see Physicians
Resouce section).
Raid deteioation in kidney function (a decline of eGFR >-% annually) waants ugent
efeal to a nehologist o intenist.
Peaation fo kidney elaceent teatent equies a iniu of onths theefoe
efeal fo consideation of kidney elaceent should take this into account.
Many atients with CKD also have diaetes and/o heat disease. Exlaining the linkage
etween these conditions and how teating one condition enefts othes ay lessen the
sychological iact of seveal seaate diagnoses.
4
III. Supporting patient self-management
Peole with CKD have ette outcoes if they take an active ole in the anageent of thei own
condition and they should e encouaged to do so. Denial often associated with gief eaction
is coon in atients with chonic disease affecting a vital ogan. Effots to intoduce eventive
lifestyle and edical theay ay fail until undestanding and accetance have een achieved.
CKD cae teas ae skilled at dealing with this issue.
To suot atient self-anageent the hysician should:
uot atients though the ocess of acceting the diagnosis of a chonic illness.
Ensue that atients undestand the ilications of the diagnosis and thei ole in self-
anageent.
Hel atients identify a suot tea.
Involve atients in defning the est ossile goals fo cae including lifestyle odifcations
such as soking cessation healthy diets weight anageent execise and social suot.
Encouage atients to onito thei own ogess though the use of diaies o logooks to
tack clinical values and self-onito BP (and lood glucose whee aoiate).
Reinfoce lifestyle odifcations at each visit.
Exlain and discuss the esults of investigations and consultations.
CHRONlC KlDNEY DlSEASE lDENTlFlCATlON, EvALUATlON AND MANAGEMENT OF PATlENTS
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Diagnostic Code:
Identify counity esouces that can ovide atients with the infoation skills and suot
needed to undestand and anage thei condition and diect o efe atients to those
esouces.
Patient self-anageent esouces ae listed in Chronic Kidney Disease: A Guide for Patients,
ae availale at www.BCGuidelines.ca
IV. Meeting care objectives
The cae of CKD atients is vey siila to cae of any atient with a chonic illness thus siila
inciles should e alied. Evidence indicates that the cae of chonic diseases such as CKD
can e ioved y the ileentation of egula scheduled eviews of clinical and laoatoy
aaetes.
Physicians ae encouaged to:
Ceate a atient egiste to identify all atients with iaied kidney function in thei actice.
Paticiate in a counity o ovincial atient egiste wheeve ossile.
Use a fow sheet fo each atient with kidney disease. (ee Aendix C fo sale fow sheet.)
Use an oganized ecall syste to ensue that laoatoy investigations and susequent offce
eviews ae efoed at egulaly scheduled aoiate intevals.
Review atient ecods to ensue cae ojectives ae et.
Thee is inceasing evidence that at lowe levels of eGFR atients eneft fo inclusion in
ultidiscilinay clinics. It is ecoended that iay cae hysicians seek ootunities within
thei counities to ensue these esouces ae accessed.
67

Rationale
This guideline outlines stategies that ay hel the iay cae actitione eet the colex
needs of esons with CKD including accuate and tiely diagnosis exloation of its etiology and
aoiate anageent of coon factos affecting ogession and co-oid conditions.
CKD is a seious oulation health ole with a signifcant iact on individuals failies society
and health sevices. It is often associated with othe coon chonic diseases such as diaetes
hyetension and heat disease. Based on oulation studies the estiated evalence of signifcant
kidney iaient (eGFR < 6 l/in) in Bitish Coluia is 4 eole aoaching the
evalence of Tye II diaetes; howeve ecause any cases ae undiagnosed this is likely a tue
signifcant undeestiate.
Thee is inceasing awaeness of CKD in all actices.

CKD inceases the isk of cadiac oidity

and otality to levels ten ties that of oulation ean isk in addition to lacing esons at
isk of end stage enal disease equiing dialysis.
9
Recent studies have deonstated that the
esence of iaied kidney function wosens ognosis fo length of hosital stay oidity and
otality.
43
Thus while not all eole with kidney disease will equie dialysis they ae all at
highe isk fo oo outcoes advese eactions to edications and inteventions and eisodes of
acute kidney failue.
44
The outcoe of atients who go on to dialysis eains oo with ten e cent annual otality; the
oveall fve-yea suvival ate is wose than that of all cances excet cance of the lung.
6
Evidence
clealy indicates that effots to contol hyetension and oteinuia (and hyeglyceia in esons
with diaetes) can event o ostone the develoent of ogessive kidney function decline.
7
793333334
Howeve levels of cae fo ilde stages of CKD eain suotial and actitiones
often do not ovide sceening and anageent in accodance with ulished guidelines.
336 37
CHRONlC KlDNEY DlSEASE lDENTlFlCATlON, EvALUATlON AND MANAGEMENT OF PATlENTS
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Diagnostic Code:
The effcacy of statins in a oulation with CKD is cuently unde evaluation in the HARP tial.
3
Until
the esults ae eoted asic isk eduction aoaches ae ecoended as ovided in the BC
clinical actice guideline Cardiovascular Disease - Primary Prevention.
39
Fo eole without heat
disease a Faingha isk-ased aoach to teatent with statins is suggested fo eole with
a ten-yea coonay heat disease (CHD) isk of % o oe. Teatent of the high isk oulation
should e to an LDL taget of . ol LDL/L o a atio of TC/HDL of < 4.
The BC clinical actice guideline Diabetes Care ecoends a isk-ased aoach fo liid
anageent with teatent to an LDL taget of . ol/L fo high-isk atients (> % CHD isk
using the UKPD calculato).
4
This aoach is consistent with the ecent APEN tial which showed
no eneft using statins fo eole with low to odeate isk of CHD (low isk % sokes)
4
and the
CARD tial which showed a eneft fo oulation at highe-isk (3% sokes).
4
Fo eldely atients
(7+ yeas) the PROPER tial found that statins did not educe CHD and stoke events in en and
woen without CHD.
43

References
. Gill J Malyuk R Djudjev O et al. Use of GFR equations to adjust dug doses in an eldely ulti-ethnic
gou a cautionay tale. Nehol Dial Tanslant 7;():94-9.
. National Kidney Foundation. K/DOQI clinical actice guidelines fo chonic kidney disease: evaluation
classifcation and statifcation. A J Kidney Dis ;39() ul :-66.
3. Levey A Atkins R Coesh J et al. Chonic kidney disease as a gloal ulic health ole:
aoaches and initiatives a osition stateent fo Kidney Disease Ioving Gloal Outcoes.
Kidney Int 7;7(3):47-9.
4. anak MJ Levey A choolweth AC et al. Kidney disease as a isk facto fo develoent
of cadiovascula disease: a stateent fo the Aeican Heat Association Councils on Kidney
in Cadiovascula Disease High Blood Pessue Reseach Clinical Cadiology and Eideiology and
Pevention. Ciculation 3;(7):4-69.
. Levin A Bakis G Molitch M et al. Pevalence of anoal seu vitain D PTH calciu and
hoshous in atients with chonic kidney disease: esults of the study to evaluate ealy kidney
disease. Kidney Int 7;7:3-.
6. Da Roza G Loewen AH Djudjev O et al. tage of CKD edicts seoconvesion afte heatitis B
iunization: ealie is ette. A J Kidney Dis 3;4(6):4-9.
7. Tivedi H Pang MM Caell A et al. lowing the ogession of chonic enal failue: econoic
enefts and atients esectives. A J Kidney Dis ;39:7-9.
. Coyle D Rody R ooka et al. Cost-effectiveness of iesatan 3 g given ealy vesus late in
atients with hyetension and a histoy of tye diaetes and enal disease: a Canadian esective.
Clin The 7;9(7):-3.
9. Guidelines and Potocols Advisoy Coittee. Hyetension Detection Diagnosis and Manageent.
[Clinical Pactice Guideline]. Availale fo www.BCGuidelines.ca. Accessed August .
. Go A Chetow GM Fan D et al. Chonic kidney disease and the isks of death cadiovascula events
and hositalization. N Engl J Med 4;3(3):96-3.
. Teel M van de Giet M chwazfeld C et al. Pevention of adiogahic-contast-agent-induced
eductions in enal function y acetylcysteine. N Engl J Med ;343(3):-4.
. Koenda P Zalunado N Bunett et al. Consevative outatient enootective otocol in atients
with low GFR undegoing contast angiogahy: a case seies. Clin Ex Nehol 7;(3):9-3.
3. Kael J Calissi P. Nehology: 3. afe dug esciing fo atients with enal insuffciency. CMAJ
;66(4):473-7.
4. Koenda P Levin A. Analysis of cadiovascula disease and kidney outcoes in ultidiscilinay
chonic kidney disease clinics: colex disease equies colex cae odels. Cu Oin Nehol
Hyetens 6;():6-6.
. Goldstein M Yassa T Dacouis N et al. Multidiscilinay edialysis cae and oidity and otality of
atients on dialysis. A J Kidney Dis 4;44(4):76-4.
6. Cutis BM Ravani P Maleti F et al. The shot- and long-te iact of ulti-discilinay clinics in
CHRONlC KlDNEY DlSEASE lDENTlFlCATlON, EvALUATlON AND MANAGEMENT OF PATlENTS
10
Diagnostic Code:
addition to standad nehology cae on atient outcoes. Nehol Dial Tanslant ;():47-4.
7. Heelgan BR Manns BJ Zhang J et al. Association etween ultidiscilinay cae and suvival fo
eldely atients with chonic kidney disease. J A oc Nehol 7;(3):993-9.
. tevens L A Cooe ingh et al. Detection of chonic kidney disease in non-nehology actices:
an iotant focus fo intevention. BCMJ ;47(6):3-.
9. Valadid CT Klein R Moss E et al. The isk of cadiovascula disease otality associated with
icoaluinuia and goss oteinuia in esons with olde-onset diaetes ellitus. Ach Inten Med
;6():93-.
. Canadian Institute fo Health Infoation. CORR eots teatent of end-stage ogan failue in
Canada 99 to 4 (6 Annual Reot). 7 Feuay [3 ages]. Availale fo htt://secue.
cihi.ca/cihiwe/disPage.js?cw_age=PG_7_E&cw_toic=7&cw_el=AR__E#full. Accessed
August 4 .
. Culleton BF Lason MG Wilson PW et al. Cadiovascula disease and otality in a counity-ased
cohot with ild enal insuffciency. Kidney Int 999;6(6):4-9.
. Cutis BM Pafey P. How can the cadiac death ate e educed in dialysis atients? ein Dial
;():-4.
3. Huhies K tigant C Levin A et al. Outcoes afte ecutaneous coonay inteventions in atients
with CKD: ioved outcoe in the stenting ea. A J Kidney Dis ;4(6)-9.
4. Levin A. Pevalence of cadiovascula daage in ealy enal disease. Nehol Dial Tanslant ;6
ul :7-.
. Heelgan BR Zhang J Manns BJ et al. Pogession of kidney dysfunction in the counity-
dwelling eldely. Kidney Int 6;69():-6.
6. Aun C toddat J Mackin P et al. ignifcance of icoaluinuia in long-duation tye diaetes.
Diaetes Cae 3;6(7):44-9.
7. Diaetes Contol and Colications Tial Reseach Gou. The effect of intensive teatent of diaetes
on the develoent and ogession of long-te colications in insulin-deendent diaetes ellitus.
N Engl J Med 993;39(4):977-96.
. Modifcation of the Diet in Renal Disease tudy Gou. The effects of dietay otein estiction and
lood-essue contol on the ogession of chonic enal disease: odifcation of diet in enal disease
study gou. N Engl J Med 994;33(3):77-4.
9. Diaetes Contol and Colications Tial (DCCT) Reseach Gou. Effect of intensive theay on
develoent and ogession of nehoathy in the DCCT. Kidney Int 99;47:73-.
3. Bakis GL. Lowe lood essue goals fo atients with diaetes: the National Kidney Foundation
consensus eot. J Clin Hyetension ;369-7.
3. Heat Outcoes Pevention Evaluation (HOPE) tudy Investigatos. Effects of aiil on
cadiovascula and icovascula outcoes in eole with diaetes ellitus: esults of the HOPE study
and MICRO-HOPE sustudy. Lancet ;33(9):3-9.
3. RENAAL tudy Investigatos. Effects of losatan on enal and cadiovascula outcoes in atients with
tye diaetes and nehoathy. N Engl J Med ;34():-6.
33. Duncan L Heathcote J Djudjev O et al. ceening fo enal disease using seu ceatinine: who ae
we issing? Nehol Dial Tanslant ;6():4-6.
34. ACE Inhiitos in Diaetic Nehoathy Tialist Gou. hould all atients with tye I diaetes ellitus
eceive angiotensin-conveting enzye inhiitos? A eta-analysis of individual atient data. Ann Inten
Med ;34():37-9.
3. Valdeano F Gole T Muihead N et al. Chonic kidney disease: why is cuent anageent
uncoodinated and suotial? Nehol Dial Tanslant ;6 ul 7:6-4.
36. Powe NR. Ealy efeal in chonic kidney disease: An enoous ootunity fo evention. A J
Kidney Dis 3;4():-7.
37. tigant C tevens L Levin A. Nehology: 4. tategies fo the cae of adults with chonic kidney
disease. CMAJ 3;6():3-6.
3. HARP tudy of Heat and Renal Potection. Clinical tial infoation availale at www.shainfo.og
Accessed August 4 .
39. Guidelines and Potocols Advisoy Coittee. Cadiovascula Disease Piay Pevention. [Clinical
Pactice Guideline]. Availale at www.BCGuidelines.ca. Accessed August 4 .
CHRONlC KlDNEY DlSEASE lDENTlFlCATlON, EvALUATlON AND MANAGEMENT OF PATlENTS
11
Diagnostic Code:
Contact Information
Guidelines and Potocols Advisoy Coittee
PO Box 964 TN PROV GOVT
Victoia BC VW 9P
Telehone: 9-347 E-ail: hlth.guidelines@gov.c.ca
Fax: 9-47 We site: www.BCGuidelines.ca
4. Guidelines and Potocols Advisoy Coittee. Diaetes Cae. [Clinical Pactice Guideline]. Availale at
www.BCGuidelines.ca. Accessed August 4 .
4. Kno RH dEden M ilde JG et al. Effcacy and safety of atovastatin in the evention of
cadiovascula end oints in sujects with tye diaetes: the Atovastatin tudy fo Pevention of
Coonay Heat Disease Endoints in non-insulin-deendent diaetes ellitus (APEN). Diaetes Cae
6;9(7):47-.
4. Colhoun H Betteidge DT Duington PN et al. 4. Piay evention of cadiovascula disease
with atovastatin in tye diaetes in the Collaoative Atovastatin Diaetes tudy (CARD):
ulticente andoised laceo-contolled tial. Lancet 4;364(943):6-96.
43. hehed J Blauw GJ Muhy MB et al. Pavastatin in eldely individuals at isk of vascula disease
(PROPER): a andoised contolled tial. Lancet ;36(9346):63-3.
This guideline is ased on scientifc evidence cuent as of the Effective Date.
This guideline was develoed y the Guidelines and Potocols Advisoy Coittee aoved y the
Bitish Coluia Medical Association and adoted y the Medical evices Coission.
The inciles of the Guidelines and Potocols Advisoy Coittee ae to:
encouage aoiate esonses to coon edical situations
ecoend actions that ae suffcient and effcient neithe excessive no defcient
eit excetions when justifed y clinical cicustances.
Appendices
Aendix A Physician Resouces
Aendix B Calculating eGFR: Convesion Tale
Aendix C Chonic Kidney Disease Flow heet
Aendix D Chonic Kidney Disease A Guide fo Patients
Associated Documents
The following docuents accoany this guideline:
uay
Disclaimer
The Clinical Pactice Guidelines (the Guidelines) have een develoed y the Guidelines and Potocols Advisoy
Coittee on ehalf of the Medical evices Coission. The Guidelines ae intended to give an undestanding
of a clinical ole and outline one o oe efeed aoaches to the investigation and anageent of the
ole. The Guidelines ae not intended as a sustitute fo the advice o ofessional judgent of a health cae
ofessional no ae they intended to e the only aoach to the anageent of clinical oles.
Location Hospital Clinic Name Phone Number
Aotsfod Fase Health Kidney Cae Clinic ..................................... 64 -374
Kaloos RIH Kidney Clinic ............................................. 34-49
Kelowna KGH Renal Health Clinic ...................... 6-43 ext 336
uey MH Kidney Cae Cente ................................... 64 7-763
Penticton PRH Renal Health Clinic (Pe-dialysis) .............. 77-7
Pince Geoge PGRH Outatient Renal Clinic ............................. 6-747
Tail Kio Wellness Cente Kidney Cae Clinic ..................................... 364-34
Vancouve t. Pauls Kidney Function Clinic .............................. 64 6-9
Vancouve VGH Heodialysis Unit ..................................... 64 7-4
Victoia RJH Kidney Cae Clinic ....... 37-4 o 37-4

BC Provincial Renal Agency (BCPRA)
PHA uite 7-3 Buad teet Vancouve BC V6Z H3
Phone: 64 7-734; Fax: 64 7-7366; www.cenalagency.ca
The BC Povincial Renal Agency is a collaoative of enal health ofessionals who coodinates the cae
of atients with kidney disease in BC.
Kidney Foundation of Canada (BC Branch)
64 736-977 (Vancouve aea) 67- (elsewhee in BC); Fax: 64 736-973
www.kidney.c.ca; e-ail: info@kidney.c.ca

The Kidney Foundation ovides educational ateials elated to vaious asects of kidney disease and
teatent and offes a nue of atient sevices. The Foundation has facilitated educational sessions on
chonic kidney disease fo faily hysicians. Fo oe infoation lease efe to the We site o contact
the BC Banch.
National Kidney Foundation (USA)
The National Kidney Foundation We site www.kidney.og includes a section fo health cae
ofessionals as well as on-line access to the K/DOQI guidelines.
Further information on nephrotoxic drugs
Kael J Calissi P. Nehology: 3. afe dug esciing fo atients with enal insuffciency. CMAJ
;66(4):473-477
www.fnoteook.co/Renal/Pha/NhtxcDgs.ht
PHYSlClAN RESOURCES
Chronic Kidney Disease
B C R e n a l A g e n c y
An Agency of the Provincial Health Services Authority
Effective Date: etee etee
BRITISH
COLUMBIA
MEDICAL
ASSOCIATION
Stage1=>90ml/minwithabnormalitiesonUAorUS
Stage2=6089ml/minwithabnormalitiesonUAorUS
Stage3=3059ml/min
Stage4=1529ml/min
Stage5=<15ml/min
Women AGE (YEARS)
-Ceatinine -39 4-49 -9 6-69 7-79
4 49 4 3
9 3 4 96 93 9
6 69 93 79 77 7
7 79 79 7 7 67 6 64
9 6 63 6 7
9 99 6 3 4
9 3 49 47 46 44 43
9 4 44 4 4 4 39
9 44 4 39 37 36 3
3 39 4 37 3 34 33 3
4 49 37 34 33 3 3 3
9 34 3 3 9
6 69 3 9 7 6 6
7 79 3 7 6 4
9 6 4 3
9 99 6 4 3
9 3
9 3 9 9
9 9
3 39 9 9 7 7
4 49 7 7 6
9 9 7 6 6 6
6 69 7 6 6
7 79 6 6 4
9 7 6 4 4 4
9 99 6 4 4 3 3
Calculating eGFR: Conversion Table
The MDRD and Cockcoft-Gault calculatos used to calculate eGFR ae availale at www.kidney.og.
S-Creatinine to eGFR Conversion Table
Fo those hysicians whose laoatoies ae not yet ale to calculate eGFR the following tales
ovide aoxiate eGFR values y gende. Values have een calculated using the MDRD calculation
fo use with standadized ceatinine assays (Levey A et al. Ann Inten Med 6;4(4):47-4) and
should e consideed aoxiate only. Note that noal eGFR = -l/in/.73

. The use
of the calculatos o tale elow does not equie a 4-hou uine sale collection.
Aendix B to Chonic Kidney Disease Identifcation Evaluation and Manageent of Patients
men AGE (YEARSj
-Ceatinine -39 4-49 -9 6-69 7-79
4 49 9 76 69 63 9
9 4 34 3 6 3
6 69 7 4
7 79 6 9 94 9 6
9 9 7 76 74
9 99 74 7 69 67 6
9 7 66 64 6 6
9 6 6 7 4
9 9 4 49 4
3 39 4 4 46 4 44
4 49 46 44 4 4 4
9 46 4 4 39 3 37
6 69 43 39 3 36 3 3
7 79 4 37 3 34 33 3
9 37 34 33 3 3 3
9 99 3 3 3 3 9 9
9 33 3 9 7
9 3 9 7 6
9 3 7 6 6 4
3 39 6 4 4 3
4 49 7 4 3
9 6 4 3
6 69 3
7 79 4 9
9 3 9 9
9 99 9 9
Stage1>90ml/minwithabnormalitiesonUAorUS
Stage2=6089ml/minwithabnormalitiesonUAorUS
Stage3=3059ml/min
Stage4=1529ml/min
CHRONIC KIDNEY DISEASE FLOW SHEET
NAME OF PATIENT
This Flow heet is ased on the Guideline Chonic Kidney Disease
We site: htt://www.cguidelines.ca
DATE OF BIRTH EX
M F
RIK FACTOR AND CO-MORBID CONDITION
DATE
BP WEIGHT
Ls Kg
LABS (ost ecent)
VISITS
ANNUALLY OR AS CLINICALLY INDICATED
CARE OBJECTIVES
HLTH/BCMA 6 (REV. /)
SELF MANAGEMENT (Discuss with patient)
Diaetes
HTN
CAD
Cadioyoathy
CHF
A1C Cr/eGFR ACR
oke
Alcohol/ustance ause
Oesity (taget BMI < )
Othe:
REMINDERS:1)ESTABLISHREGULARVISITANDLABWORKSCHEDULE2)REFERTONEPHROLOGYTEAM3)*
Annual Flu: Pneuovax (qy):
VACCINATIONS
DATE DATE DATE
NOTE: CLINICAL TATU CARE OBJECTIVE AND FOLLOW-UP IUE
Guidelines &
Protocols
Advisory
Committee
AGE AT DIAGNOI
Atial filation
Othe ahythia
Valvula HD
PVD
Liid anoality
< 3/ BMI < 7% tale*
%
fo
aseline
evey visit evey visit
(DM only)
q3
q6 q6-
LAB WORK (at least annually)
Heatitis B (seies coleted):
DATE
Exlain diagnosis and ilications of CKD
elf onito with fow sheet
Review edication list (see evese)
Discuss CVD isk assessent & anageent stategies
Kidney-secifc education
Identify suot tea and esouces
oking cessation: Quit Now 77 4-33
Weight execise and nutition status
Poote sychosocial health

RENAL U/
(IF INDICATED) DATE:
HTN
OTHER: REULT:
TYPE OF CKD: DM POLYCYTIC KD
LIPIDS
Hgb
WNR/-
on tx
LDL
< . high-
isk (<7 ys)
Ratio
<4.
TSAT
>%
ANEMIA MINERAL METABOLISM
Ca
. - .
Phos
.7 - .4
PTH
WNR
Albumin
WNR
DATE
DIAGNOI
eGFR<10-15%ANNUALDECLINE
Astha
COPD
Live disease
Deession
BAELINE REVIEW
BRITISH
COLUMBIA
MEDICAL
ASSOCIATION
MEDICATION
NAME OF DRUG PRECRIBED BY DOE /FREQUENCY NOTE AND TART/TOP DATE
Chronic Kidney Disease
A GUlDE FOR PATlENTS
B C R e n a l A g e n c y
An Agency of the Provincial Health Services Authority
BRITISH
COLUMBIA
MEDICAL
ASSOCIATION
Effective Date: etee etee
What is chronic kidney disease (CKD)?
Kidneys ae as iotant to you health as you heat o you lungs. haed like kidney eans and aout the size of
you fst you kidneys ae located on eithe side of you sine unde the lowe is. Thei ain task is to eove waste
oducts fo you lood. You kidneys also oduce iotant hoones that egulate soe of you odys functions
and hel alance wate and ineals in you ody.

Chonic kidney disease (CKD) efes to a edical condition whee you kidneys aility to flte wastes fo you ody
is iaied. CKD usually stats slowly and ogesses ove a nue of yeas. If diagnosed and teated ealy CKD ay
e slowed down o stoed. Howeve if it kees getting wose CKD ay lead to kidney failue also called End-tage
Renal Disease (ERD). If you have ERD teatent otions include dialysis o a kidney tanslant. These teatents
can hel you stay healthy and continue you daily activities.
Thee is no cue fo CKD the goal of teatent is to kee the kidneys functioning as long as ossile y detecting
and teating the disease at its ealy stages. oeties if teated ealy all that ay e needed is a change in you diet
contol of you lood essue and/o soe secifc edication.
What are the symptoms of kidney disease?
CKD is a silent disease. Most eole do not have any sytos in the ealy stages. ytos egin when ost
of you kidney function is lost. ytos that ay show u as you kidney function deteioates include fequent
headaches fatigue and itching all ove the ody.
As kidney disease wosens the ody is unale to get id of waste oducts and excess wate. This condition is called
ueia. In addition to ealie sytos you ay exeience:
Fequent uination o assing less uine
welling in legs ankles feet face and/o hands
Metallic o ad taste in outh
Nausea and voiting
Loss of aetite
Who is at risk of developing CKD?
The leading causes of kidney failue ae diabetes and high blood pressure. These conditions intefee with the flteing These conditions intefee with the flteing
aility of the kidneys and can lead to kidney failue. Ealy diagnosis and caeful anageent of these conditions can Ealy diagnosis and caeful anageent of these conditions can
delay and even event the onset of kidney failue. Talk to you docto if you have diaetes o hyetension. Othe Talk to you docto if you have diaetes o hyetension. Othe
factos that incease a esons isk of develoing CKD include:
Faily histoy of kidney disease (e.g. olycystic kidney disease)
Cetain ethnic gous (Fist Nations Pacifc Islandes)
Oveuse of anti-infaatoy dugs and ain-killes
Infection o injuy to the kidneys (e.g. gloeulonehitis)
How can I prevent or control CKD?
Thee is no cue fo CKD ut y leaning oe aout you illness and taking an active at in anaging you health
you ay e ale to kee you kidneys functioning longe. Conside using the Chronic Kidney Disease Flow Sheet to
onito you ogess. You can take this fow sheet with you when you visit you docto. Othe iotant things you
can do include:
Control diabetes
If you have diaetes kee you lood glucose levels as close to noal as ossile. Along with taking you
edications as escied kee you weight unde contol and execise egulaly. You docto should outinely test
whethe you kidneys ae functioning oely.
hotness of eath
Feeling cold
Toule concentating dizziness
Leg ain/uscle cas
Kidney Foundation of Canada (BC Branch)
Tel: 64 736-977 (Vancouve aea)
67- (elsewhee in BC)
Fax: 64 736-973
Eail: info@kidney.c.ca

The Kidney Foundation has atient suot gous in
any aeas of BC as well as educational ateial and
offes shot te fnancial assistance fo those in need.
BC Provincial Renal Agency (BCPRA)
Tel: 64 7-734
Eail: ca@ca.uc.ca
The BC Povincial Renal Agency is a collaoative of enal health ofessionals who coodinate the cae
of atients with kidney disease in BC.
BC Health Guide
Infoation on kidney disease can e found in the BC HealthGuide Online at www.chealthguide.og o
in the BC HealthGuide Handook ovided fee to households thoughout the ovince. The 4-Hou BC
HealthGuide NuseLine uts you in touch with a Registeed Nuse any tie day o night just y calling one of
the following nues:
Local calling within Geate Vancouve: 64 -47
Toll-fee elsewhee within BC: 66 -47
Deaf and heaing-iaied toll-fee ovince wide: 66 TTY-47
Control high blood pressure (hypertension)
High lood essue causes kidney daage and will also cause kidney function to deteioate oe quickly. Contol
you high lood essue to 3/. Wok with you docto to fnd the anti-hyetension edications that wok est
fo you. Kee you weight unde contol execise egulaly and educe you salt intake to hel kee you lood
essue at a healthy level.
Lead a smoke free life
To hel event kidney disease sto soking and avoid exosue to second hand soke.

Eat well
If you have CKD it is iotant to have a diet that eets you nutitional needs. Lean how oe food choices
can hel you. Talk to a nutitionist o dietitian aout a food lan that is ight fo you. Be awae that cetain foods can
cause kidney function to deteioate oe quickly. A diet that is too high in otein can cause oles.
Exercise and control your weight
Execising egulaly is one of the est things you can do to iove you oveall health. Execise hels you to lowe
you lood suga and lood essue achieve a healthy weight iove you heat and lung health and iove
you hysical ental and eotional well eing.
Do not overuse over-the-counter drugs
Polonged and fequent use of anti-infaatoy and anti-ain edications can daage you kidneys. Talk to you
docto o haacist to fnd out how to use non-escition edication that wont daage you kidneys.
Reduce stress
Recognize that it ay take tie to adjust to CKD so e atient and set ealistic goals. Kee involved in the
leasues activities and esonsiilities of daily life and shae you feelings with faily and close fiends. Conside
joining a suot gou.
Resources for People with Chronic Kidney Disease
The Living with Kidney Disease atient anual
oduced y The Kidney Foundation of Canada is an
iotant educational efeence fo eole living with
kidney disease. The anual is availale in English &
Fench on the Kidney Foundation we site:
www.kidney.ca/ulications-eng.ht
It is also availale in English Fench Chinese Italian
Potuguese & Punjai fo the BC Banch.