Management of CKD in primary care

Appropriate management of chronic kidney disease (CKD) in primary care involves several key components:

• Regular follow-up: Arrange regular monitoring based on clinical judgement, considering the stage of CKD and risk factors for progression.
• Assessment and management of underlying causes and risk factors: Identify and treat reversible causes of CKD and manage comorbidities such as hypertension, diabetes, and cardiovascular disease.
• Medication review: Avoid or reduce potentially nephrotoxic drugs, especially during acute illness, and clearly explain when to restart any discontinued medicines.
• Blood pressure control: Assess hypertension and manage according to urinary albumin:creatinine ratio (ACR):
  • For ACR ≤30 mg/mmol, manage hypertension as in adults without CKD.
  • For ACR >30 mg/mmol, offer an ACE inhibitor or angiotensin receptor blocker (ARB) titrated to the highest tolerated dose; avoid combining renin-angiotensin system antagonists.
  • Aim for blood pressure targets: systolic <140 mmHg and diastolic <90 mmHg if ACR <70 mg/mmol; systolic <130 mmHg and diastolic <80 mmHg if ACR ≥70 mg/mmol.
  • For people aged ≥80 years with type 1 diabetes, aim for systolic <150 mmHg and diastolic <90 mmHg.
• Lifestyle and psychological support: Manage lifestyle risk factors such as smoking, obesity, and physical inactivity; offer support for anxiety or depression.
• Monitoring disease progression: Monitor kidney function and albuminuria regularly, adjusting frequency based on stage and risk factors.
• Patient education and self-management: Provide tailored information and education about CKD, its progression, treatment options, and self-management strategies; enable access to medical data to support informed decisions.
• Referral criteria: Refer to nephrology if there is:
  • Uncontrolled hypertension despite ≥4 antihypertensive drugs at therapeutic doses.
  • ACR ≥70 mg/mmol (unless due to diabetes and appropriately treated).
  • ACR >30 mg/mmol with persistent haematuria after excluding UTI.
  • Sustained significant decline in eGFR.
  • Suspected rare or genetic causes, renal artery stenosis, or complications such as renal outflow obstruction.

This comprehensive approach aims to slow CKD progression, manage complications, and prepare patients for potential renal replacement therapy if needed.

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