1. Detection, monitoring and referral of chronic kidney disease
Canadian Society of Nephrology
Implementation Committee
2007
This slide kit was developed for Primary Care givers by the Canadian Society of Nephrology Implementation Committee.
A new position paper on the care and referral of adult patients with reduced kidney function was published on the CSN website in September of 2006 and the Society felt it was best if a document/presentation kit were to be prepared to complement this document dealing specifically with the issue of estimated GFR (eGFR) as it may be a new approach to following renal function to some clinicians.
These recommendations address those at risk for chronic kidney disease and are not meant to consider all potential reasons to refer to nephrology (eg. hematuria).

2. Key messages Who to test for chronic kidney disease
What tests to order
What to do with the results
These are the three key points that we hope clinicians will remember.
- use case-finding approach to CKD in high-risk individuals
- test using eGFR (kidney function) and assessment of urine protein (kidney damage) to identify individuals with CKD as well as the subgroup at risk of progressive disease
- abnormal findings need serial monitoring as many will improve on repeat testing and serial monitoring helps to identify those with progressive renal disease

3. Identify patients in your practice at high risk for Chronic Kidney Disease
Patients with hypertension
Patients with diabetes mellitus
Patients with atherosclerotic coronary,
cerebral or peripheral vascular disease
- Patients with heart failure
Patients with unexplained anemia
Patients with a family history of end stage renal disease
First nations peoples
eGFR <30
eGFR 30-60
eGFR >60
Consider reversible factors:
Medication - Volume depletion
Intercurrent illness - Obstruction
Repeat tests in weeks
Individualized follow up
and treatment
CKD is diagnosed in this group only
if other renal abnormalities are present
(i.e. proteinuria, hematuria, anatomical)
eGFR <30
eGFR 30-60
Nephrology referral
recommended
Follow eGFR at 3 months then serially
Assess for persistent significant proteinuria
Implement risk reduction
eGFR < 30
or progressive decline in eGFR
or persistent significant proteinuria
or inability to attain treatment targets
Stable eGFR 30-60
and
no significant proteinuria

4. What is Chronic Kidney Disease
The presence of Kidney Damage or an eGFR < 60 ml/min/1.73m2 and
Present for ≥ 3 months and
Not treated with dialysis or transplant
Kidney Damage is defined well in the Document on Identification, Evaluation and Management of Patients with Chronic Kidney Disease as pathologic abnormalities or markers of damage, including abnormalities in blood, urine or imaging tests studies*
To be clear, the type of patient that is referred to is one where the renal function is stable and there is no significant amount of proteinuria present. Chronic kidney disease can be present in patients who have eGFRs over 60ml/min but who have abnormalities of urinalysis such as persistent proteinuria or hematuria. These patients should be referred to a Nephrologist
There is no expectation of any Primary Care Physician to manage kidney disease that is progressive or with other complicating elements such as significant proteinuria.
The diagnosis of CKD is only present in patients with eGFR ≥60ml/min if other
abnormalities (i.e. proteinuria, hematuria, anatomical) are also present.

5. Who should be tested for CKD?
CSN endorses a case finding approach
to testing for CKD, which should be
focused on high-risk groups.
CSN does not endorse
mass population screening for CKD
with either serum creatinine based tests or with urine dipstick testing.

6. Who should be tested for CKD?
Patients with diabetes mellitus
Patients with hypertension
Patients with heart failure
Patients with atherosclerotic coronary, cerebrovascular or peripheral vascular disease
Patients with unexplained anemia
Patients with a family history of ESRD
First nations peoples

7. Clinical case Joe is a 68 year old welder
Past Medical History: appendectomy age 15, hypertension x 4 years, elevated cholesterol x 1 year, Type 2 DM x 1 year
Smoker- 1 pack a day since age 21
Etoh- a case of beer on the weekend
Allergy- none known
Family History- father MI age 50, mother HTN age 48
Medications- hydrochlorothiazide 25 mg po od, amlodipine 5mg po od, metformin 1000 mg po bid
Weight 75 kg
BP 149/84 mmHg
Illustrating the power of eGFR using clinical cases

8. Joe should be screened for CKD because he has several risk factors.
Can you name them?
Could discuss SCORED study (Arch Int Med Feb 2007; 167: )– Here Joe has a history of hypertension as well as DM. SCORED also considered age as a risk factor

9. Which test would you choose to assess Joe’s renal function?
Serum creatinine
24 hour urine collection
Nuclear medicine scan
eGFR
Each item in this list has elements that preclude them from being dependably used and easily accessed in the day to day clinical assessment of patient renal function in a reliable and accurate manner.
Commonly voiced concerns about 24hr urine collections include 1) instructions are routinely misunderstood leading to inaccurate collections and unreliable inaccurate results 2) Patients find it difficult to commit to an entire day’s worth of “testing” 3) routine under or over collections etc
Nuclear medicine tests are not practical nor cost effective ways in which to follow renal function
Serum Creatinine and urea measurements alone often are misinterpreted by health care professionals, the most common of which is that despite a value being in the “normal range” it reflects a GFR that is significantly reduced for that patient’s age , gender and body mass. This will be explored more in the presentation.

10. Joe’s labs Na 138 mmol/L K 4.5 mmol/L Cl 103 mmol/L HCO3 23 mmol/L
Glucose (R) 6.4 mmol/L
Urea 10.1 mmol/L
Creatinine 123 µmol/L
CBC normal
HgB A1C 5.6%
Ca mmol/L
PO4= mmol/L
Albumin 38 g/L
TC 7.60 mmol/L
TG 2.06 mmol/L
LDL(C) 5.43 mmol/L
HDL(C) 1.23 mmol/L
Upper limit of Cr in this lab is 130umol/L

11. Joe’s serum creatinine is in the normal range, doesn’t that mean his kidney function is also normal?

12. Assessing Joe’s renal function using eGFR
54 ml/min / 1.73m2
(Stage 3 CKD)
Clearly, Joe’s renal function is not normal
despite a normal serum creatinine
This highlights some of the problems with eGFR in that the CG equation is recognized for overestimating renal function.
The MDRD equation has been validated for use in the CKD population but it is not as easy to use and not everyone has access to a computer in their clinic area.
The point is made however that despite either equation’s pitfalls the patient is better served by having their eGFR calculated and then repeated in a serial fashion to determine if it is changing. Stable chronically reduced eGFR with minimal proteinuria does not necessarily need to be seen by a nephrologist.
The presenter can mention that this corresponds to Stage 3 CKD and that the staging system for CKD will be covered a little later on in the presentation

13. Why use eGFR? It gives the health care practitioner
a different sense as to a patient’s level of
renal function that they may not have
appreciated by using simple serum
creatinine measurements.
The advantage of these equations over serum creatinine measurements alone is that the latter are recognized as being poor indicators of early CKD.

14. Measuring renal function: what’s eGFR?

15. GFR Glomerular filtration rate (GFR):
is the volume of fluid filtered from the
renal glomerular capillaries into the
Bowman’s space per unit time.
Normal for a 20 year old is ~ 120ml/min

16. Methods to assess GFR Serum urea Serum creatinine Serum cystatin C
Timed urine collections
Creatinine clearance
Inulin clearance
Calculated GFR calculations
based on serum creatinine
many formulas including Cockcroft Gault and MDRD
Nuclear medicine methods
There is a great article in BMJ October 2006 that reviews all these methods
How to measure renal function in clinic practice. Traylor, Mactier, Geddes and Fox, BMJ 2006; 333:

17. The perfect marker doesn’t exist ! Endogenous Freely filtered
Not secreted or reabsorbed
Inexpensive to measure
doesn’t exist !

18. Problems with creatinine
Stevens L et al, NEJM 2006; 354:

19. Problems with timed collections
Cumbersome
Prone to error
No longer recommended in most situations

20. Problems with other methods
Cystatin
Inulin
Nuclear medicine (iothalamate, EDTA etc)
Complex
Time-consuming
Expensive
Not practical for serial monitoring

21. Creatinine based approximations
1) Cockcroft-Gault equation
CrCl (ml/min)= (140-age) x actual weight (kg) x 1.2 (if male) SCreat (µmol/L)
2) MDRD (Modification of Diet in Renal Disease)
6 variable or abbreviated version
GFR(ml/min/1.73m2)=170 (PCr) x (Age) x (0.762 if female) x (1.21 if African American) x (serum urea) x (Albumin)+0.318
Weight probably not available for lab to calculate
Can use this slide to point out importance of adjusting for race in African Americans.
These are the two main methods whereby an eGFR is generated by the lab.
The CSN endorses the use of standardized methods to measure serum creatinine. Creatinine is measured in different ways in labs across Canada. It would be reasonable for the clinician to familiarize themselves with the methods employed in their local lab.
Not all labs in Canada generate an eGFR value along with the serum creatinine. Pioneers in the area such as BC and Alberta have this but other areas do not have eGFR reporting at this time. Moreover, one lab may use the CG formula and another the MDRD equation. Again, the clinician is advised to familiarize themselves with the methods employed in their local lab.
Both formulae have been validated in various populations with moderate to severe impairment of GFR; however they may be less reliable in patients with near normal (>60ml/min/1.73m2) GFR or in patients with markedly abnormal body composition (eg extreme obesity, cachexia, paralysis, amputations)
There remain controversies as to the applicability of these equations to various ethnic groups, the very elderly and to the non-referred populations with modest decreases in renal function which are summarized on the next slide.
Lab has patient age and gender – can do abbreviated version

22. eGFR equation provisos
eGFR calculations may be less reliable in:
individuals with near normal GFR (>60 ml/min/1.73m2)
individuals with markedly abnormal body composition
extreme obesity
cachexia
paralysis
amputations
Controversies exist as to the applicability of these formulae to various ethnic groups and the very elderly
Remind them of adjusting MDRD for african-american race

23. Estimate of Glomerular Filtration Rate (eGFR)
It is not recommended that clinicians rely on serum creatinine measurements alone when assessing kidney function.
CSN calls for the reporting of kidney function as an estimate of glomerular function rate (eGFR) using equations and standardized creatinine measurements
If neither eGFR reporting, nor calculators are available to a physician, tables based on serum creatinine and other variables are available to provide approximations of eGFR.

24. Developed by the BC Medical Services Commission, Guidelines and
Protocols group

25. Developed by the BC Medical Services
Commission, Guidelines and
Protocols group

26. Is it just about GFR? Should also assess urine protein losses
24 hour urines are no longer recommended
For same reasons as with GFR
Urine dipsticks are affected by hydration status
Quantify protein excretion with random urine for:
Urine albumin to creatinine ratio or
Urine protein to creatinine ratio
Can simplify it to explain that eGFR measures renal function (clearance) while proteinuria/albuminuria identifies renal injury and is associated with prognosis

27. What do those values mean?
ACR
(mg/mmol)
PCR
24 hour
urine
>3
N/A
~30 mg day
(albumin)
<40
<60
~ 500 mg/day
(protein)
>60
>100
~900 mg/day
Microalbuminuria
(ie in diabetics)
These examples were chosen since they are the numbers that people may already be familiar with and include values that should trigger referral to Nephrology.
Can also use this slide to re-emphasize that microalbuminuria in diabetics shows evidence of renal injury despite preserved renal function. Demonstrates why need to look at function (eGFR) as well as injury (protein)
Alarm values
to refer

28. Who should be tested for CKD?
Patients with diabetes mellitus
Patients with hypertension
Patients with heart failure
Patients with atherosclerotic coronary, cerebrovascular or peripheral vascular disease
Patients with unexplained anemia
Patients with a family history of ESRD
First nations peoples
Summing up what we’ve covered so far

29. What tests to order? Assess kidney function with eGFR
As reported by lab
As calculated using equations (and PDA!)
As estimated by tables
Quantification of protein with random urine samples
Urine albumin to creatinine or
Urine protein to creatinine
Summing up what we’ve covered so far

30. What to do with the results
Now that I know Joe’s GFR is not normal what should I do?

31. What to do with the results
Is one eGFR measurement enough?
Consider reversible factors
Assess risk of progressive renal disease
who needs referral to Nephrology

32. Natural history of elevated creatinine levels
Marcotte and Godwin, Canadian Family Physician 2006;52: ,e1-5
1434 patients in a family medicine practice
57 patients had an elevated initial serum Cr levels (>130umol/L) and subsequent Cr levels within 4-5 years of follow-up
Initial serum Cr
Latest serum creatinine (umol/L)
<130
>300 26 12 5 2 3 1
This article was referenced because it is a primary care population in the Canadian setting. Other examples could be used.
More than half of those with initially elevated Cr levels saw them return to normal (including 50% of those with initial Cr >300)
Only 7 patients progressed to a higher level over 4-5 years of followup
In all 1434 patients average age was 63, 18% were diabetic, 47% were hypertensive, only 4% were referred to Neph

33. Is one eGFR measurement enough?
Decisions about investigation, treatment or referral should not be made based on a single isolated test of kidney function
In a primary care setting, many patients will show improvement or normalization of kidney function upon repeat testing.
The diagnosis of CKD is based on serial measurements of kidney function and it is not possible to diagnose CKD on the basis of a single serum creatinine concentration transformed through equations.
These are statements from the position paper

34. For patients with a new finding of an eGFR between 30-60ml/min/1.73m2
CSN recommends that clinicians determine
the stability of the patient’s eGFR
Repeat test within 2-4 weeks,
and then in 3-6 months
There will always be cases that do not fit with these recommendations (for example in a 35 year old otherwise well individual a finding of an eGFR below 60 would probably lead to repeat testing sooner than 2-4 weeks). Primary care givers are still asked to use their clinical judgement

35. Consider reversible factors
Intercurrent illness
Volume depletion
Medications
NSAIDs, aminoglycosides, IV contrast dye
Obstruction
An abdominal ultrasound may be indicated at eGFRs <60ml/min/1.73m2
May also mention fibrates, different forms of NSAIDs (suppositories, creams)

36. Back to Joe
You measure Joe’s eGFR in 2 weeks and then again in 3 months and it is unchanged
You order an ultrasound and it is normal
His urinalysis is normal

37. Conclusions about Joe
Given the stability of these we can conclude that he has stable CKD.
It is important to continue to serially follow his renal function.
Serial measurement is a cornerstone of chronic kidney disease management.

38. CSN recommends that most patients with
non-progressive CKD can be managed by
non-nephrologists without referral.
The recognition that many patients with an eGFR between 30 and 60 ml/min/1.73m2
do not have a high risk of
progressive kidney disease is important.
Need to address two questions
- why look for CKD if most will not be progressive
- who does need referral to Nephrology

39. CKD is common

40. Estimated prevalence of CKD in Canadians ≥ 20 years old
Stage 1 CKD > 90 ml/min ,000
Stage 2 CKD 60 – 89 ml/min 720,000
Stage 3 CKD 30 – 59ml/min 1,032,000
Stage 4 CKD 15 – 29 ml/min 48,000
Stage 5 CKD < 15 ml/min 24,000
This reference is an excellent one for Primary Care Physicians on CKD.
It also outlined the scope of the problem when it extrapolated figures from US data (which was taken from K/DOQI) and gave an idea of the numbers of Canadians who had CKD and expressed these according to their stage of CKD
This slide also introduces the idea of the various stages of CKD
Numbers are estimates based on an extrapolation of US data
Stigant, C, et al. CMAJ 2003;168:

41. Other common conditions also managed by primary care physicians
CVD
38.7% in diabetic men
30.7 % in diabetic women
Thyroid disease
1/20 (Thyroid Fdn of Canada)
Hypertension
28%
Type 2 DM
8-10 % worldwide
References for these figures are
CVD:
DM:
BP: Hajjar, Kotchen and Kotchen. Annual Rev Public Health 2006; 27:465-90
CKD is a common general health problem

42. Estimated prevalence of CKD in Canadians ≥ 20 years old
Stage 1 CKD > 90 ml/min ,000
Stage 2 CKD 60 – 89 ml/min 720,000
Stage 3 CKD 30 – 59ml/min 1,032,000
Stage 4 CKD 15 – 29 ml/min 48,000
Stage 5 CKD < 15 ml/min 24,000
ESRD is not common
Aim of slide is to demonstrate that although CKD is common (approx 1 in 10 adults) ESRD is not common
Stigant, C, et al. CMAJ 2003;168:

43. If many patients with CKD do not progress to end stage renal failure why then as a primary care physician should I even be looking for them using eGFR?

44. Patients with CKD have high rates of cardiovascular disease
ESRD is not the problem
Patients with CKD have high rates of cardiovascular disease
and many patients die before progressing to end stage renal failure thus it is important to screen for CKD.
Risk of cardiovascular death is 100 X the risk of progressing to ESRD

45. This study shows nicely why we must pay attention to those patients with CKD. In addition to their renal disease they are at significantly greater risk for health complications related to cardiovascular disease.
This study published in the NEJM in 2004 looked at 1,120,295 adults (55% were female) where a serum creatinine had been measured between 1996 and 2000 who had no history of been treated with dialysis or renal transplant.
They examined the multivariate association between the estimated GFR (eGFR) and the risks of death, risk of cardiovascular event and hospitalizations.
They found an independent, graded association was observed between a reduced eGFR and the risk of death, cardiovascular events and hospitalizations in a large community based population
Go,A et al. NEJM 2004;351:

46. Quick Tips on Management of CKD
Implement measures to slow rate of CKD progression
Treat to target BP <130/80; most will need 3 or more meds, diuretics and salt restriction are very useful
Target urine ACR <40 or PCR <60. ACEI and/or ARB are first line therapies for albuminuria or proteinuria
Control blood sugar in diabetes, target HbA1C <7%
Implement measures to modify CV risk factors
Follow guidelines as per groups at highest risk for CV disease
Minimize further kidney injury
If possible, avoid nephrotoxins such as NSAIDs, aminoglycosides, IV and intra-arterial contrast etc
If contrast is necessary, consider prophylactic measures (if eGFR <60)
Remember to adjust dosages of renally excreted medications
Full guidelines on the management of CKD will be soon forthcoming from the CSN. In the mean time these “Quick Tips” are part of the CSN position paper on the Care and Referral of Adult Patients with Reduced Renal Function. This is an abbreviated version that fits on the algorithm. A full version is available as a one page handout (see CSN website for both algorithm and handout)

47. Joe: three years later His CKD is no longer stable
You have continued to follow his eGFR and notice that it is now 42 ml/min/1.73m2
All clinical targets (BP, HBA1C, cholesterol) are stable
No intercurrent illnesses
His CKD is no longer stable
Refer to Nephrology

48. Who should be referred to a Nephrologist?
Patients with acute renal failure
Patients with eGFR <30ml/min/1.73m2
Patients with progressive loss of renal function
Persistent significant proteinuria (present on 2 out of 3 samples)
on dipstick or
quantified PCR >100mg/mmol or
quantified ACR >60 mg/mmol.
Inability to achieve treatment targets or other difficulties in the management of the CKD patient

49. Violet
78 year old female
longstanding patient of a colleague’s – followed for her hypertension and “mild” renal failure
You are on call and see her because she is c/o nausea and lethargy
This example illustrates the value of eGFR as opposed to Cr for assessment of renal function as well as the value of serial monitoring
Date
today
1 yr ago
2 yrs ago
5 yrs ago
Serum Creat
(µmol/l)
184
168
156
138

50. Using an “eGFR approach”
Date
today
1 yr ago
2 yrs ago
5 yrs ago
Serum Cr
(µmol/L)
184
168
156
138
eGFR
(ml/min/1.73m2) 24 27 30 35
The presenter should use this table to illustrate how the patient’s renal function was never normal in the first place and that it may have been underestimated all along in her management
The presenter should also point out that the serial measurement of the value shows that her renal function is in decline

51. This woman’s renal disease may have been underdiagnosed
Using eGFR may have given a more
accurate measure of her renal function
Serial measurement of eGFR
is a powerful tool for the clinician
May also chose to discuss that her nausea and lethargy may signal decreased oral intake and her eGFR may be acutely low due to volume depletion
Nephrology referral is recommended for this patient

52. Linda 54 yo female comes for routine annual physical
no problems identified
normal physical examination
family history of ESRD
All her labs are normal – serum creatinine is 90 µmol/l
Lab automatically reports an eGFR of 60 ml/min/1.73m2
What do you do with this eGFR value?
Should she be referred to a Nephrologist?
This example illustrates the importance of proteinuria in the diagnosis of CKD
90% confidence intervals on this eGFR calculation range from 42-78

53. Identify patients in your practice at high risk for Chronic Kidney Disease
Patients with hypertension
Patients with diabetes mellitus
Patients with atherosclerotic coronary,
cerebral or peripheral vascular disease
- Patients with heart failure
Patients with unexplained anemia
Patients with a family history of end stage renal disease
First nations peoples
eGFR <30
eGFR 30-60
eGFR >60
Consider reversible factors:
Medication - Volume depletion
Intercurrent illness - Obstruction
Repeat tests in weeks
Individualized follow up
and treatment
CKD is diagnosed in this group only if other renal abnormalities are present
(i.e. proteinuria, hematuria, anatomical)
eGFR <30
eGFR 30-60
Nephrology referral
recommended
Follow eGFR at 3 months then serially
Assess for persistent significant proteinuria
Implement risk reduction
eGFR < 30
or progressive decline in eGFR
or persistent significant proteinuria
or inability to attain treatment targets
Stable eGFR 30-60
and
no significant proteinuria

54. Linda: continued
Evaluation of her urine shows no significant amount of proteinuria (ACR <40mg/mmol) and no hematuria
She is followed annually
Two years later
same eGFR
blood pressure is 146/94
persistent proteinuria with ACR > 60mg/mmol
Progressive CKD = referral to Nephrology
Here the presenter could emphasize (again) the importance of serial monitoring of the eGFR and of proteinuria.
Patients who have eGFR >60ml/min but no proteinuria or hematuria do not have renal disease. Serial monitoring of these patients and the important parameters of eGFR, BP and proteinuria allow for disease progression to be picked up using easy to do and relatively inexpensive means.
Also emphasizes the importance of significant proteinuria in identifying patients more likely to develop progressive CKD
Proteinuria is a surrogate marker of renal disease

55. Dave 81 year old man, new to your practice
ASHD, stent placed 2 years ago
PSA >100 led to biopsy and diagnosis of prostate cancer, being treated with hormone therapy alone
On atorvastatin 40 mg, aspirin 81 mg, ramipril 5 mg
Bp 144/82, nil else on exam
Cr 167, eGFR 36, ACR 0.7
This example is used to demonstrate the role primary care docs have in following CKD that is non-progressive

56. Dave
Old labs from previous MD show Cr umol/L over last 3 years
What would you do?
Stable CKD, follow serially
Achieve BP <130/80
CV risk reduction – LDL at high risk level
Watch for renally excreted medications – adjust doses (metformin, glyburide, digoxin etc.) or avoid
Would not need Nephro

57. Summary Who should be tested for CKD? Patients with diabetes mellitus
Patients with hypertension
Patients with heart failure
Patients with atherosclerotic coronary, cerebrovascular or peripheral vascular disease
Patients with unexplained anemia
Patients with a family history of ESRD
First nations peoples

58. Summary What tests should be ordered?
eGFR to assess kidney function
random urine sample to assess for significant persistent proteinuria
What should be done with the results?
follow serially
assess for proteinuria
implement risk reduction strategies
Monitoring for evidence of progressive disease
- declining eGFR
- persistent significant proteinuria

59. Acknowledgements
Financial support for the development and distribution of these educational materials was provided by unrestricted grants from Amgen Canada and Bristol Meyers Squibb

60. Quick Tips on Referral and Management of Chronic Kidney Disease
Most patients with non-progressive CKD can be managed without referral to a nephrologist. The goals of therapy are listed below:
Consider reversible factors, such as medications, intercurrent illness, volume depletion, or obstruction. An abdominal ultrasound may be indicated when eGFR <60 ml/min/1.73m2.
Minimize further kidney injury by avoiding, if possible, nephrotoxins such as NSAID’s, aminoglycoside antibiotics, IV contrast, etc (if eGFR < 60 ml/min/1.73m2).
Remember to adjust dosages of renally excreted medications.
Implement measures to slow the rate of progression of CKD:
Target BP is < 130/80 mmHg. Most patients will need 3 or more medications. Diuretics and salt restriction are very useful, and if needed, consider furosemide BID dosing when eGFR < 30 ml/min/1.73m2
Target urine protein/creatinine ratio (mg/mmol) is < 60 (< ~ 500 mg/day) or target urine albumin/creatinine ratio (mg/mmol) is < 40. ACEI and/or ARB are first line therapies in patients with albuminuria or proteinuria.
Control blood sugar in diabetes, target HbA1C < 7%.
Implement measures to modify CV risk factors (NB: CV risk >> ESRD risk).
Follow the Canadian Hypertension Education Program, the Canadian Diabetes Association, and the Canadian Cardiovascular Society guidelines as per groups at highest risk for CV disease.
Referral to a nephrologist is recommended for:
acute kidney failure
eGFR < 30 ml/min/1.73m2. (CKD stage 4 and 5)
progressive decline of eGFR
urine protein/creatinine ratio (PCR) > 100 mg/mmol (~900 mg/24 hours) or urine albumin to creatinine ratio (ACR) > 60 mg/mmol (~500 mg/24 hr)
inability to achieve treatment targets
NOTE: detailed CSN CKD management guidelines are under development, these quick tips should be considered as an interim approach.Insert Quick Tips sheet from the CSN CKD document
This slide is obviously too hard to read but serves as a reminder to show participants the one page handout which features this information on one side as well as a summary of the key messages from this slide set
The CSN Guidelines committee is producing a document regarding the management of patients with CKD which will provide more detailed and evidenced based information (expected winter 2007)