Camden Chronic Kidney Disease Pathway

Test Urine

Persistent
proteinuria >1+

ACR >3.5 / PCR >15

ACR 30 / PCR 50

ACR 70 / PCR 100

ACR >250 / PCR >300

Microalbuminuria

If hypertensive
consider ACEi/ARB

BP control - ACEi/ARB
Refer

Nephrotic range
Urgent Referral

Check spot urine for

ACR (or PCR)

CKD 1 or

eGFR > 60

Check eGFR

eGFR 45 59

eGFR 30 - 44

eGFR 15 29

CKD 3A

CKD 3B

CKD 4

2
eGFR >60 normal unless
evidence of kidney disease
(structural abnormality

Moderate decrease in GFR, with or without

other evidence of kidney damage
If new, confirm with repeat within 2 weeks

eGFR <15

CKD 5

Severe decrease in
GFR +/- other evidence
of kidney damage

Established renal
failure

and/or proteinuria and/or

proteinuria + haematuria)

Other groups at risk:

Afro-Caribbean & South Asian populations
Structural renal tract disease, kidney stones or
prostatic hypertrophy
Multisystem diseases with potential kidney
involvement eg SLE
Family history or hereditary kidney disease
Patients on long term nephrotoxic drug eg
Lithium, NSAIDS

Acute Kidney Injury

eGFR is unreliable in AKI so
review of sudden deterioration in
serum creatinine should be used to
identify AKI
Review all previous results to
determine rate of decline
Creat >1.5x baseline

Blood Pressure, Creatinine and eGFR, Hb, Urine Protein Creatinine Ratio (PCR)

Other
Investigations

Renal Function (eGFR) should be measured

annually in all patients with
Diabetes, Hypertension, Cardiovascular
Disease and Heart Failure

Potassium,

Calcium ,
+

Phosphate
Bicarbonate,

Vitamin D,

PTH

Renal Ultrasound for:

Progressive CKD
(eGFR falls > 5 within 1 yr
or > 10 within 5 yrs)
Visible or persistent invisible haematuria

Repeat
within 5 days
Creat >2x baseline

Urinary sepsis, Lower Urinary Tract Symptoms

Every 12 months

6 monthly

3 monthly

Family history of polycystic kidney disease

(Aged over 20)

Refer acute
medicine
Creat >3x baseline

Management in Primary Care

Management

Treat modifiable risk factors

Lifestyle advice
Smoking, weight, exercise, salt &
alcohol intake

Blood Pressure control

Monitor BP at least annually
Target < 140/90 (non-diabetics)
or < 130/80 (urine PCR >100 or diabetic )
If urine ACR >30 or PCR >50 or if diabetic with
microalbuminuria: ACEI or ARB first line
(avoid if K+ >5 mmol/L)

Stop nephrotoxic drugs

Blood Pressure Control
Influenza & Pneumococcus
immunisation

Assess Cardiovascular Risk

Consider Statin, Aspirin
Cardiovascular Risk
CKD is a powerful risk factor for
cardiovascular disease
Statins: Secondary prevention: all
with established vascular disease:
MI, angina, stroke, Heart Failure due
to CHD, diabetics >40 yrs. Primary
prevention: if 10yr CVD risk >20%
Aspirin: Secondary prevention: All
with established vascular disease ,
Primary prevention: Consider if 10yr
CVD risk >20%

Check Creatinine, K+: Before start, after 2 weeks &

after each dose change
If Creatinine increases by >30% or GFR falls by
>25%, Repeat with K+ and seek advice
Hyperkalaemia
If K+ > 6 mmol/L
Check no haemolysis
Check diet (Bananas,
soft fruit, fruit juice,
chocolate)
Stop NSAIDs and
LoSalt, Stop K+
retaining diuretics

Mineral metabolism
is disturbed in most
patients with CKD4/5:

25 OH Vit D:
If less than 75 nmol/l
Calceos / Adcal D3 2 tabs
daily or cholecalciferol
20,000 iu weekly

Stop ACEI/ARB if
hyperkalaemia persists

References
This pathway based on the North Central London CKD Guide 2011
DOH 2005 - NSF for renal disease
RCP National Collaborating Centre for Chronic Conditions - CKD Guidance
The Renal Association - UK CKD Guidelines
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

Stage 4 or 5 CKD
Refer RFH
renal unit

Reasons for Referral

CKD 4 & 5
Referral or discussion advised even if dialysis may
not be appropriate in conjunction with secondary
care. Discuss prior to referral where elderly/frail/
terminal illness & stable CKD/BP/Hb.
Isolated proteinuria / PCR > 100
Or PCR >45 and microscopic haematuria
Macroscopic haematuria
(after negative urological evaluation)
Progressive fall in eGFR
(>15 mL/min over 12 months)

AKI phone
07908422116

CICS Referral

Information needed on referral

General medical history
Urinary symptoms
Medication (dates of starting and
stopping ACEI/ARB if applicable)
Urgent referral
Examination e.g. BP, oedema,
bladder

Acute Kidney Injury

(Acute renal failure)

Urine dipstick for blood and protein

Fall of eGFR of 25% during first 2 months on
ACEI / ARB
Uncontrolled Hypertension
(BP > 150/90 on 3 agents)

Anaemia (after exclusion of other causes)

Where Hb 11 or if symptomatic
Persistently abnormal serum K+, Ca2+, PO4
Suspected renal artery stenosis, rare or genetic
causes or underlying systemic illness,
e.g. SLE, vasculitis, myeloma

Malignant hypertension

Urine culture and PCR

(if protein present)
FBC, Creatinine & eGFR, Urea, Na+,
K+, Albumin, Calcium, Phosphate,
Cholesterol, HbA1c (in diabetes)

Hyperkalaemia
(K+ > 7 mmol/L)
Nephrotic syndrome

List all old Creatinine results (as well

as any eGFR reports) with dates
Result of renal ultrasound if available.

V2.2 Links updated Feb 16

Pathway created by Alex Warner July 2012
Reviewed by Alex Warner
Sept 2015
Review due
Sept 2018