CKD mx in primary care?

For patients with a confirmed diagnosis of chronic kidney disease (CKD), primary care should arrange regular follow-up, with the frequency determined by clinical judgment. Management involves assessing and managing risk factors and comorbidities, including the underlying causes of CKD and any potentially nephrotoxic drugs ¹,². Key Management Areas:

• Monitoring: Regularly monitor for disease progression, adjusting frequency based on CKD stage and risk factors ¹,².
• Hypertension Management: Assess for hypertension. For those with an ACR over 30 mg/mmol, offer an ACE inhibitor or ARB as first-line treatment, titrated to the highest tolerated dose. Do not combine renin-angiotensin system antagonists. Blood pressure targets vary based on ACR: < 70 mg/mmol aim for <140/90 mmHg (120-139/80-89 mmHg), and >= 70 mg/mmol aim for <130/80 mmHg (120-129/70-79 mmHg). For individuals aged 80+ with type 1 diabetes, aim for <150/90 mmHg ¹,².
• Lifestyle Modifications: Encourage exercise, healthy weight, and smoking cessation ³.
• Dietary Advice: Offer advice on potassium, phosphate, calorie, and salt intake, tailored to CKD severity. Ensure dietary advice is provided with education and supervision to prevent malnutrition ³. Do not offer low-protein diets (less than 0.6 to 0.8 g/kg/day) ³.
• Information and Education: Provide high-quality, tailored information and education programmes to patients and their families/carers to facilitate informed choices about treatment and self-management ³.
• Psychological Support: Address psychological aspects of coping with CKD and offer access to support services ³.
• Risk Assessment: Inform patients about their 5-year risk of needing renal replacement therapy using the 4-variable Kidney Failure Risk Equation ³.

For specialist consideration:

• Referral to a nephrology specialist is indicated if hypertension remains uncontrolled despite at least four antihypertensive drugs at therapeutic doses ¹,².
• Referral criteria for specialist assessment include a 5-year risk of needing renal replacement therapy greater than 5%, an ACR of 70 mg/mmol or more (unless appropriately treated for diabetes), an ACR over 30 mg/mmol with haematuria, a sustained eGFR decrease of 25% or more within 12 months, a sustained eGFR decrease of 15 ml/min/1.73 m² or more per year, known or suspected rare/genetic causes of CKD, or suspected renal artery stenosis ³.
• Refer to urology for renal outflow obstruction ¹,².
• Consider discussing management with a specialist if there are concerns but referral is not immediately necessary ¹,².
• Specific medications may require dose adjustments or avoidance in renal impairment, such as ACE inhibitors (start low, adjust as tolerated) ⁷, potassium citrate/bicarbonate (avoid if eGFR < 45 mL/min/1.73m², caution if 45-59 with elevated potassium) ⁸, potassium chloride (avoid in severe impairment, monitor closely) ⁹, and atorvastatin (initial dose 20mg, specialist advice for eGFR < 30) ⁶. Finerenone should be avoided if eGFR < 25 mL/min/1.73m² ⁵. Tobramycin requires annual renal function monitoring ⁴.