CKD Assessment and Plan - Outpatient Internal Medicine
Diagnostic Confirmation and Staging
Confirm CKD diagnosis by documenting abnormalities present for ≥3 months: eGFR <60 mL/min/1.73 m² and/or albuminuria ≥30 mg/g creatinine. 1
Initial Laboratory Assessment
- Serum creatinine with eGFR calculation using CKD-EPI equation (race-free) 1
- Random spot urine albumin-to-creatinine ratio (UACR) - preferred over 24-hour collection 1
- If eGFR discordance suspected or critical decision-making, add cystatin C for combined eGFRcr-cys calculation 1
- Confirm abnormal UACR with 2 of 3 specimens over 3-6 months (exclude transient causes: exercise within 24h, infection, fever, CHF, marked hyperglycemia, menstruation, marked hypertension) 1
CKD Staging
- GFR Categories: G1 (≥90), G2 (60-89), G3a (45-59), G3b (30-44), G4 (15-29), G5 (<15 mL/min/1.73 m²) 1, 2
- Albuminuria Categories: A1 (<30 mg/g), A2 (30-299 mg/g), A3 (≥300 mg/g) 1, 2
- Current stage: G___ A___
Establish Chronicity and Etiology
- Review prior creatinine/eGFR values, imaging showing reduced kidney size/cortical thinning, or pathology showing fibrosis 1
- Assess for diabetic kidney disease (DM duration >10 years in type 1, may be present at type 2 diagnosis) 1
- Consider non-diabetic causes if: type 1 DM <5 years duration, active urine sediment (RBCs/casts), rapidly declining eGFR, rapidly increasing/very high UACR, no retinopathy in type 1 DM 1
Cardiovascular and Renal Risk Assessment
Baseline Testing
- 12-lead ECG - assess for LVH, atrial fibrillation 1
- Lipid panel (LDL, HDL, total cholesterol, triglycerides) 1
- HbA1c if diabetic 1
- Electrolytes, calcium, phosphate, intact PTH (if eGFR <45) 3, 4
- CBC - assess for anemia of CKD 3, 4
Optional HMOD Assessment (if resources permit)
- Echocardiography - evaluate for LVH, diastolic dysfunction, established CVD 1
- Renal ultrasound with Doppler - assess kidney structure, exclude renovascular disease if indicated 1
Pharmacologic Management
Blood Pressure Control
- Target BP <140/90 mmHg 1, 5
- ACE inhibitor or ARB for patients with UACR 30-299 mg/g and hypertension 1
- ACE inhibitor or ARB strongly recommended for UACR ≥300 mg/g and/or eGFR <60 1
- Do NOT use ACE-I/ARB for primary prevention if BP normal, UACR <30, and eGFR normal 1
- Continue ACE-I/ARB if creatinine rises ≤30% without volume depletion 1, 6
Glucose Control (if diabetic)
- Target HbA1c individualized, generally ≤7% 1, 5
- SGLT2 inhibitor if eGFR ≥20 mL/min/1.73 m² - reduces CKD progression and cardiovascular events 1, 5, 6
- GLP-1 receptor agonist for increased cardiovascular risk 5
- Finerenone (non-steroidal MRA) if SGLT2-i contraindicated/not tolerated and UACR ≥300 mg/g 1
Cardiovascular Risk Reduction
Proteinuria Reduction
- Target ≥30% reduction in UACR to slow CKD progression 1
Medication Safety
- Avoid NSAIDs and other nephrotoxins 3, 4
- Adjust drug dosing based on eGFR (antibiotics, oral hypoglycemics, others) 3, 4
- Monitor creatinine and potassium when using ACE-I/ARB/diuretics 1, 6
Dietary Management
- Protein restriction to 0.8 g/kg/day maximum for non-dialysis stage 3+ CKD 1, 5
- Sodium restriction <2 g/day 5
- Balanced diet high in vegetables, fruits, whole grains, fiber, plant-based proteins 5
Monitoring Schedule
Frequency Based on Stage (times per year)
- G1-G2 with A1: Annual 1
- G3a with A1: 1-2x/year; with A2: 2x/year; with A3: 3x/year 1
- G3b with A1: 2x/year; with A2: 3x/year; with A3: 3-4x/year 1
- G4-G5: 3-4x/year regardless of albuminuria 1
Parameters to Monitor
- Serum creatinine, eGFR, UACR 1
- Electrolytes (especially potassium when on ACE-I/ARB/MRA) 1, 6
- Calcium, phosphate, PTH (if eGFR <45) 3
- CBC (anemia screening) 3
- HbA1c (if diabetic, at least 2x/year) 5
Define CKD Progression
- Change in eGFR category PLUS ≥25% decline in eGFR 1
Nephrology Referral Criteria
- eGFR <30 mL/min/1.73 m²
- Rapidly progressive kidney disease (meeting progression criteria above)
- Uncertainty about CKD etiology
- Difficult management issues
- UACR ≥300 mg/g with inadequate response to treatment
Complications Management
Monitor and Treat as Indicated
- Hyperkalemia (K >5.5 mmol/L) 6, 3
- Metabolic acidosis 3, 4
- Hyperphosphatemia 3
- Vitamin D deficiency 3
- Secondary hyperparathyroidism 3
- Anemia (target hemoglobin per guidelines) 3, 4
Patient Education
- CKD diagnosis, stage, and prognosis
- Medication adherence importance, especially ACE-I/ARB and SGLT2-i
- Avoid nephrotoxins (NSAIDs, contrast without prophylaxis)
- Dietary modifications
- Importance of BP and glucose control
- When to seek urgent care (AKI symptoms, severe hyperkalemia symptoms)