1

.. 2558
Clinical Practice Recommendation for the Evaluation and Management of
Chronic Kidney Disease in Adults 2015

(Chronic Kidney Disease, CKD)

(End Stage Renal Disease, ESRD)
(hemodialysis) (peritoneal dialysis)
(kidney transplantation)

.. 2555-2557 .. 2557-2559
.. 2552

3 30-31 .. 2557

.. 2555-2557

.. 2557-2559

.. 2558

(.) ()

.. 2558

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2:
3:
4:
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10:
11:
12:
13:
14:
15:
16:
17:

1
2
4
5
6
8
9
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14
15
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18
19
20
21
22
23

1: ..2555-2557
..2557-2559
2: ..2555-2557
..2557-2559

24
25

1
2
3 GFR
4 CKD-EPI
5 GFR
ACEIs ARBs
6
7 statins
8

2
7
11
12
15

.. 2558

(Strength of Recommendations)
++

(cost effective) / (strongly recommended)

/ (recommended)

+/-

(neither recommended nor
against)

(against)

--

(strongly against)

(Quality of Evidences)
I
I-1
I-2

II
II-1
II-2
II-3

II-4

(systematic review)
(randomized, controlled clinical trial)
(well-designed, randomized,
controlled clinical trial) 1

(systematic review)
(non-randomized, controlled clinical trial)
(well-designed, nonrandomized, controlled clinical trial)
(cohort)
(case-control)

multiple time series

III
III-1
III-2

(descriptive study)
(fair-designed, controlled clinical trial)

IV
IV-1

(clinical consensus)
(case series)
2

IV-2

1. (screening and consultation or referral)

2. (slowing the progression of kidney diseases)

3. (evaluation and treating complications)

4. (cardiovascular risk reduction)

5. (preparation for renal replacement therapy)

ACC/AHA/ESC
ACEIs
ACR
AER
ARBs
BMI
eGFR
ESA
CKD
CKD-EPI
GFR
Hb
KDIGO
nPNA
NSAIDs
KUB
PCR
SCr
SCysC
TSAT

American College of Cardiology/American Heart Association Task Force on Practice

Guidelines and the European Society of Cardiology
Angiotensin-converting enzyme inhibitors
Albumin-to-creatinine ratio
Albumin excretion rate
Angiotensin II receptor blockers
Body mass index
Estimated glomerular filtration rate
Erythropoietin stimulating agent
Chronic kidney disease
Chronic Kidney Disease Epidemiology Collaboration
Glomerular filtration rate
Hemoglobin
Kidney Disease: Improving Global Outcomes
Normalized protein equivalent of nitrogen appearance
Non-steroidal anti-inflammatory drugs
Kidney urinary bladder
Protein-to-creatinine ratio
Serum creatinine
Serum cystatin C
Transferrin saturation

(chronic kidney disease, CKD)

1. 3 (estimated
glomerular filtration rate, eGFR)

1.1 2 3
1.1.1 (albuminuria)
albumin excretion rate (AER) 30 mg/24h albumin-to-creatinine
ratio (ACR) 30 mg/g
1.1.2 (hematuria)
1.1.3 (electrolyte)
1.2
1.3
1.4
2. eGFR 60 ml/min/1.73m2 3

1. eGFR (++/ II)

2. (systemic diseases)
(Not Graded)
3. eGFR ( 1)
1

eGFR

(CKD stages)
(ml/min/1.73m2)
1
> 90

2
60-89

3a
45-59

3b
30-44

4
15-29

5
< 15

(1) 1 2
(2) eGFR
eGFR = 59.64 ml/min/1.73m2 60 ml/min/1.73m2
2

4. ( 2) (Not Graded)
2
albumin excretion albumin creatinine ratio (ACR)

rate (AER)

(mg/mmol)
(mg/g)
(mg/24h)
A1
< 30
<3
< 30

A2
30-300
3-30
30-300

A3
> 300
>30
> 300

(1) A3 nephrotic syndrome (AER 2,200/24h [ ACR 2,200
mg/g; 220 mg/mmol])
(2) (urine albumin strip)

1) 2) eGFR 3)
4) (Not Graded) GFR
( 3)
3 GFR

A1
A2
A3
<30 mg/g
30-300 mg/g
>300 mg/g
<3 mg/mmol 3-30 mg/mmol >30 mg/mmol

1
> 90
GFR

2
60-89
(ml/min/1.73m2)
3a
45-59
3b 30-44
4
15-29
5
<15
(: KDIGO 2012)
:
:

1. eGFR 60 ml/min/1.73m2
1.1

2. eGFR < 60 ml/min/1.73m2

2.1 (serum creatinine; SCr) eGFR
2.2 (nonsteroidal anti-inflammatory drugs; NSAIDs) angiotensinconverting enzyme inhibitors (ACEIs) / angiotensin II receptor blockers (ARBs)
3.

(protein-to-creatininie ratio, PCR)
4.


5. eGFR 7

6.

11

1

1.1 (++/ I)
1.2 (++/ II)
1.3 60 (+/ II)
1.4 (autoimmune diseases) (+/ III)
1.5 (systemic infection) (+/ III)
1.6 (cardiovascular disease) (+/ III)
1.7 (+/ III)
1.8 (gout) (+/ III)
1.9 NSAIDs (nephrotoxic agents) (+/ IV)
1.10 (renal mass) (+/ IV)
1.11 (+/ IV)
1.12 (+/ IV)
1.13 3 (+/ IV)

2
1
2.1 eGFR 1 CKD-EPI
(Chronic Kidney Disease Epidemiology Collaboration) equation (++/ II) ( 4)
4 CKD-EPI
(mg/dL)

0.7
eGFR = 144 x (SCr/0.7) -0.329 x (0.993)Age

> 0.7
eGFR = 144 x (SCr/0.7) -1.209 x (0.993)Age
0.9
eGFR = 141 x (SCr/0.9) -0.411 x (0.993)Age

> 0.9
eGFR = 141 x (SCr/0.9) -1.209 x (0.993)Age
2.1.1 (+/ II)
2.1.1.1 enzymatic method
eGFR
2.1.1.2 2
1.01 mg/dL eGFR eGFR
(CKD-EPI) ml/min/1.73m2
2.1.1.3 eGFR (creatinine-based GFR estimating equation)
CKD-EPI equation Thai
estimated GFR equation
eGFR = 375.5 x SCr(-0.848) x Age(-0.364) x 0.712 ()
2.1.1.4
() (cystatin C) (SCysC) ()
eGFR 45-59 ml/min/1.73m2

eGFR 2012 CKD-EPI creatinine-cystatin C
based GFR equation (+/-/ II)
eGFR =
0.499
1.328

, 1

, 1
0.996 [ 0.932 ]
0.8
0.8

133

SCysC (mg/dL)

min

0.8

1 max

0.8

() 24 creatinine clearance

(+/ III)

33

2.2 (dipstick)
2.2.1 1+
(++/ III)
2.2.2 /
(++/ II)
2.2.2.1 ACR (spot morning urine) 30-300 mg/g
microalbuminuria ( moderately increased albuminuria)
2.2.2.2 microalbumin (cut-off level : 20 mg/L)
albuminuria 1-2 3 albuminuria 2
3
2.3 microscopic examination
5 cells/HPF
(++/ IV)
2.4 2.1-2.3 3

(++/ IV)
2.5 (plain KUB) / (ultrasonography of KUB)
(+/-/ IV)

3
eGFR
1 (Not Graded) eGFR

(Not Graded)
3.1 1 2 12 6 ACR 300
mg/g PCR 500 mg/g
3.2 3a 6
3.2.1 4 ACR 300 mg/g PCR 500 mg/g
3.2.2 12
3.3 3b 6 4 ACR 30 mg/g
PCR 150 mg/g
3.4 4 4 3 ACR 300 mg/g
PCR 500 mg/g
3.5 5 3

55

4
4.1 (+/ II)
4.1.1 eGFR 30-59 ml/min/1.73m2 5 ml/min/1.73m2

4.2 (+/ II)

4.2.1
4.2.1.1 CKD staging eGFR 25
4.2.1.2 eGFR 5 ml/min/1.73m2
4.2.2 eGFR 30 ml/min/1.73m2
4.3
4.3.1
4.3.2 ACR 300 mg/g PCR 500 mg/g

4.3.3 4
4.3.4 20 cells/HPF
4.3.5
4.3.6 1
4.3.7

5
5.1

(Not Graded)
5.2
(body
mass index, BMI) 20-25 kg/m2 2,000 mg/day
(++/ IV)
5.3
30 mg/day PCR 150 mg/g 140/90 mmHg (++/ I-2)
5.4
30 mg/day PCR 150 mg/g 130/80 mmHg (+/ III-2)
5.5 ACR 30-300 mg/g PCR 150-500 mg/g
ACEIs ARBs (+/ III-2)
5.6 ACR 300 mg/day PCR 500 mg/g
ACEIs ARBs (++/ I-2)
5.7 ACEIs ARBs (-/ I-2)
5.8 ACEIs ARBs
(++/ I-2)
5.9 2
(++/ I-3)
5.10 ACEIs ARBs
( 5)
30 5.5 mmol/L
(++/ I-2)

77

5 GFR
ACEIs ARBs

(mmHg)
> 120
110 119
< 110
GFR (ml/min/1.73m2)
> 60
30 - 59
< 30
GFR (%)
< 15
15 - 30
> 30
(mmol/L)
< 4.5
4.6 - 5.0
>5

4-12
2-4
< 2

6-12
3-6
1-3

6
6.1
AER 500-1,000 mg/day PCR 500-1,000 mg/g 6 (+/ I-3)
6.2
(+/ II-3)
6.3 ACEIs ARBs
(+/ II-3)
6.4 ACEIs ARBs
30 mg/day (--/ I-2)
6.5 ACEIs ARBs AER 30-300 mg/day ACR
30-300 mg/g (+/ I-2)
6.6 ACEI ARB AER 300
mg/g ACR 300 mg/g (++/ I-1)
6.7 ACEIs ARBs
(-/ I-2)

99

7
7.1
(life expectancy)

7.1.1 (preprandial capillary plasma glucose) 80-130 mg/dL (4.4-7.2

mmol/L) 1-3 AER 300 mg/day

4-5 AER 300 mg/day
(+/ II)
7.1.2 (peak postprandial capillary plasma glucose) 180 mg/dL
( 10.0 mmol/L) (+/-/ II)
7.1.3 (HbA1C) 7.0
(HbA1C 6.5)


( HbA1C 7-8)

(++/ I-2)
7.2
7.2.1 biguanides (metformin): metformin eGFR 45
ml/min/1.73m2 eGFR 30-44 ml/min/1.73m2
metformin eGFR 30 ml/min/1.73m2 (-/ II-3)
7.2.2 sulfonylureas:
3-5
7.2.2.1 Glibenclamide: eGFR 30 ml/min/1.73m2 (-/ II)
7.2.2.2 Glipizide gliclazide:
eGFR 10 ml/min/1.73m2 (+/ III-1)
7.2.3 alpha-glucosidase inhibitors: acarbose eGFR 30 ml/min/1.73m2
miglitol eGFR 25 ml/min/1.73m2 (-/ III-1)
7.2.4 meglitinides: repaglinide nateglinide
eGFR 30 ml/min/1.73m2 (repaglinide 0.5 mg/day
nateglinide 60 mg/day) (+/ III-1)
7.2.5 thiazolidinediones:

(+/-/ IV-2)

10

10

7.2.6 dipeptidyl peptidase-4 (DPP-4) inhibitors:

sitagliptin saxagliptin vildagliptin
linagliptin sitagliptin 100 mg/day
50 (50 mg/day) eGFR 30-50
ml/min/1.73m2 25 (25 mg/day) eGFR 30 ml/min/1.73m2
vildagliptin 50 mg/day eGFR 50 ml/min/1.73m2
saxagliptin 2.5 mg/day eGFR 50 ml/min/1.73m2 (+/ III-1)
7.2.7 (insulins): 1 2
(HbA1C 10%
250 mg/dL (random) 300 mg/dL)

2
(eGFR 30 ml/min/1.73m2)

25 GFR 10-50 ml/min/1.73m2 50 GFR
10 ml/min/1.73m2
(+/ IV-1)

11
11

8
8.1
8.1.1 (lipid profiles) total cholesterol,
LDL cholesterol, HDL cholesterol triglyceride
(secondary causes) (+/ III-2) ( 6) fasting
triglyceride 1,000 mg/dl LDL cholesterol 190 mg/dl)
6 (secondary causes)

Nephrotic syndrome
13-cis-retinoic acid
Excessive alcohol consumption
Androgens
Hypothyroidism
Anticonvulsants
Liver disease
Oral contraceptives
Diabetes
Highly active anti-retroviral therapy
Corticosteroids
Diuretics
Cyclosporine
Beta-blockers
Sirolimus

8.1.2 (fireand-forget strategy) (+/-/ IV-1)

8.1.2.1
8.1.2.2
8.1.2.3
8.1.2.4 10 (10-year cardiovascular
risk in incidence of coronary death or non-fatal myocardial infarction)1
50 statins
8.2
8.2.1
8.2.1.1 50 eGFR 60 ml/min/1.73m2 ( 3a-5)
statins
statin/ezetimibe
combination (+/ I-2)

12

12

8.2.1.2 50 eGFR 60 ml/min/1.73m2 ( 1-2)

statins

(+/-/ II-3)
8.2.1.3 1849
statins (+/ I-2)
() (myocardial infarction or coronary revascularization)
()
() (ischemic stroke)
() 10 1
10
8.2.1.4 (+/-/ II-2)
8.2.2 ( 7)
statin
statins
7 statins ( mg/day)

Statins
1-2
3a-5
Lovastatin

Fluvastatin

80
Atorvastatin

20
Rosuvastatin

10
Simvastatin/ezetimibe

20/10
Pravastatin

40
Simvastatin

40
Pitavastatin

8.3 hypertriglyceridemia
8.3.1 hypertriglyceridemia
(++/ IV)
1

10
(1) Framingham Risk Scores Wilson PW, DAgostino RB, Levy D et al. Prediction of coronary heart
disease using risk factor categories. Circulation 1998;97:183747.
(2) SCORE Perk J, De Backer G, Gohlke H et al. European Guidelines on cardiovascular disease
prevention in clinical practice (version 2012). The Fifth Joint Task Force of the European Society of Cardiology and
Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of nine
societies and by invited experts). Eur Heart J 2012;33:16351701.

13
13

(3) PROCAM Assmann G, Cullen P, Schulte H. Simple scoring scheme for calculating the risk of acute
coronary events based on the 10-year follow-up of the prospective cardiovascular Munster (PROCAM) study.
Circulation 2002;105:3105.
(4) ASSIGN Woodward M, Brindle P, Tunstall-Pedoe H. Adding social deprivation and family history to
cardiovascular risk assessment: the ASSIGN score from the Scottish Heart Health Extended Cohort (SHHEC). Heart
2007;93:172-6.
(5) QRISK2 (Hippisley-Cox J, Coupland C, Vinogradova Y et al. Predicting cardiovascular risk in England and Wales:
prospective derivation and validation of QRISK2. BMJ 2008;336:147582.

14

14

9
9.1
(++/ I)

15
15

10
10.1
(++/ I)
10.1.1 eGFR 30 ml/min/1.73m2 ( 4-5) 0.8 /
1 (+/ II)
10.1.2 (high biological value protein)
60 (++/ III)
10.2
10.2.1 60 35 Kcal/kg (kg)/ (++/ III)
10.2.2 60 30-35 Kcal/kg (kg)/
(++/ III)

= (cm) 100
= (cm) 110
10.3
ACEIs
( 8) (++/ III)
8

(100-200 mg/ 1 )

(250-350 mg/ 1 )

10.4
90 mmol/day (2,000 mg ) (++/ III)
10.5
(++/ IV)

16

16

10.6 3-6 3.5 g/dL

(++/ I)
10.7 (dietary protein intake) 3-6
normalized protein equivalent of nitrogen appearance
(nPNA) nPNA dietary recall food record
(+/ IV)
normalized protein equivalent of nitrogen appearance (nPNA)
UNA = UUN (g N/day) + NUN (g N/day)
NUN = 0.031 g N x body weight in Kg
PNA = UNA x 6.25

UNA = urea nitrogen appearance
UUN = 24-hour urinary urea nitrogen (g N/day)
NUN = non urea nitrogen (g N/day)
PNA = protein equivalent of total nitrogen appearance (g protein/da

50 60 kg. 24-hour
Urea nitrogen 457.1 mg/dL
Creatinine
46.1 mg/dL
Volume
2,430 mL

NUN = 0.031 x 60 kg = 1.86 g N/day

UUN = (457.1 mg/dL) x (2,430 mL) = 11.11 g N/day
UNA = 11.11 + 1.86 = 12.97 g N/day
PNA = 12.97 x 6.25 = 81.06 g /day

nPNA = 81.06/60 = 1.35 g/kg/day

10.8
(+/ II)
10.9 24
3-6 (+/-/ III)

17
17

11
11.1 eGFR 45 ml/min/1.73m2 ( 3b-5)
(intact parathyroid hormone, iPTH) alkaline phosphatase
(++/ III)
11.2 (+/ II)
11.2.1 (corrected serum calcium) 9.0-10.2 mg/dL
11.2.2 2.7-4.6 mg/dL
11.3
(phosphate binder) (++/ II)
11.4 2 ergocalciferol (+/ II)
11.5 3b-5 (hyperparathyroidism)

calcitriol (active vitamin D) alfacalcidol
(vitamin D analog) (+/ II)

18

18

12
12.1
Hemoglobin (Hb) 13.0 g/dL 12.0
g/dL (Not Graded)
12.2 Hb (Not Graded)
12.2.1
() 3 1
() 4-5 6
12.2.2
() 3-5 3
12.3
12.3.1 erythropoietin stimulating
agent (ESA) transferrin saturation (TSAT)
30 ferritin 500 g/L 1-3

ESA (+/ III)
12.3.2 ESA
1-3 TSAT 30 ferritin
500 g/L
12.3.3 TSAT serum ferritin 3-6
ESA ESA (Not
Graded)
12.4 ESA
12.4.1 ESA ESA
Stroke malignancy (+/ II)
12.4.2 ESA 3-5 Hb 10 g/dL (++/ II)
12.4.3 ESA Hb 11.5 g/dL Hb
Hb 13 g/dL
(++/ II)
12.4.4 ESA (initial phase) Hb (Not
Graded)
12.4.5 ESA Hb (maintenance phase)
Hb 3 (Not Graded)
12.5
ESA

19
19

13
13.1
( 22 mmol/L) (++/ III)

20

20

14
14.1 NSAIDs cyclooxygenase-2 (COX-2) inhibitors
aminoglycosides
(Not Graded)
14.2 radiocontrast agents
radiocontrast agents low- iso-osmolar non-ionic agents
(++/ I) GFR 48-96
radiocontrast agents (++/ III)
14.3 GFR 15 ml/min/1.73m2 gadolinium-based
contrast agents gadolinium-based contrast agents
(++/ II)
14.4 GFR 30 ml/min/1.73m2 gadolinium-based contrast
agents macrocyclic chelate preparation (+/ II)
14.5 oral phosphate-containing bowel
preparations GFR 60 ml/min/1.73m2
phosphate nephropathy (++/ I)

21
21

15
15.1
(hepatitis B vaccine) 2
4 (0, 1, 2, 6 ) deltoid
1 (anti-HBs <10 IU/L) 4
(++/ II)
15.2 (influenza vaccine) (++/ II)

22

22

16
16.1
(very high risk) (++/ I-2)
16.2
(+/ III-1)
16.3
(+/ III-1)
16.4
(+/ III-1)
16.5
16.5.1 (coronary heart disease) (myocardial infarction)
16.5.1.1 (lifestyle modification)
(++/ III-1)
16.5.1.2 (aspirin) secondary prevention (+/ IV-1)
16.5.1.3 statins 8 (+/ I-2)
16.5.2 (congestive heart failure)
16.5.2.1 10 g/dL 11.5 g/dL (+/ I-2)
16.5.2.2 (+/ I-2)
16.5.2.3 ACEIs ARBs secondary prevention (+/ IV-1)
16.5.2.4 bisoprolol carvedilol secondary prevention (+/ I-2)
16.5.3 atrial fibrillation
16.5.3.1 warfarin embolic stroke (
ACC/AHA/ESC recommendation) (+/-/ IV-1)
16.5.4 (stroke)
16.5.4.1 ACEIs thiazide diuretics (+/ I-2)
16.5.4.2 secondary prevention (+/ I-2)
16.5.4.3 statins 8 (+/ I-2)
16.5.5 (peripheral arterial disease)
16.5.5.1 (++/ II-3)
16.5.5.2 secondary prevention (+/ IV-1)
16.5.5.3 cilostazol secondary prevention (+/ IV-1)

23
23

17
17.1 4 (eGFR
30 ml/min/1.73m2) (+/ IV)
17.2 4
(++/ IV)
17.3 (vascular access)
4 arteriovenous fistula
(+/ III)

24

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