Article Figures & Tables
Tables
Test Notes Recommended investigations annually for CKD stage 2–3 Creatinine, eGFR Rapid or progressive worsening in days to weeks suggests an active potentially reversible process. Electrolytes (Na, K, Cl, CO2) Target bicarbonate level ≥ 22 mmol/L, K ≤ 5.4 mmol/L. ACR Should be ordered routinely for patients with CKD, alongside creatinine and eGFR. Important component of KFRE score. Recommended Investigations for AKI or de novo CKD (in addition to above tests) Urinalysis Can help determine renal cause for CKD (e.g., glomerulonephritis, acute interstitial nephritis). Note that dipstick protein identifies only albumin and not free light chains. May miss cast nephropathy ACR Should be ordered routinely for patients with CKD. Important component of KFRE score. Urea Useful for determining volume depletion. May be elevated in gastrointestinal bleeds or in patients taking steroids. Urine electrolytes Low urine Na (FENA < 1%) is consistent with intravascular volume depletion (unreliable in context of diuretic use). Ultrasound of kidneys Assesses for structural disease (cysts, congenital abnormalities, hydronephrosis) and renal stones. Small atrophic kidneys can be suggestive of long-standing, irreversible CKD.
Consider renal Doppler to rule out renovascular disease if patient presents with marked hypertension or difference in kidney size.Serum protein electrophoresis To identify plasma cell dyscrasia (e.g., multiple myeloma), particularly important in patients who have new, unexplained anemia or hypercalcemia. 24-hour urine protein and urine electrophoresis Important to do if ACR > 300 mg/mmol (> 3 g/d). Creatine kinase levels May suggest rhabdomyolysis (e.g., patients recently started on statins with myopathy). Antineutrophil cytoplasmic antibody serology Should be ordered if urinalysis shows blood and protein and rapidly rising creatinine. CBC with blood film Fragments on blood smear and/or low platelets suggest thrombotic microangiopathy (thrombotic thrombocytopenic purpura, HUS or aHUS). Recommended tests every 3–6 months for patients with CKD stage 4–5 Creatinine, eGFR Rapid or progressive worsening in days to weeks suggests an active reversible process. Urea Useful for determining volume depletion. May be elevated in gastrointestinal bleeds or in patients taking steroids. Electrolytes (Na, K, Cl, CO2) Target bicarbonate level ≥ 22 mmol/L, K ≤ 5.4 mmol/L. Calcium panel (Ca, PO4, Mg, albumin, PTH) Target a PTH < 3 times the upper limit of normal for patients with CKD stage 4 and 5. ACR To convert ACR to 24-h albuminuria, multiply by 10 for women and by 15 for men. Important for calculation of KFRE. CBC, ferritin, transferrin saturation Ferritin may be elevated in CKD or AKI.
Ferritin < 200 μg/L or transferrin saturation < 20% suggests iron deficiency.Note: ACR = albumin-to-creatinine ratio, aHUS = atypical hemolytic uremic syndrome, AKI = acute kidney injury, Ca = calcium, CBC = complete blood count, CKD = chronic kidney disease, Cl = chloride, CO2 = bicarbonate, eGFR = estimated glomerular filtration rate, FENA = fractional excretion of sodium, HbA1C = glycated hemoglobin percentage, HUS = hemolytic uremic syndrome, K = potassium, KFRE = Kidney Failure Risk Equation, Mg = magnesium, Na = sodium, PO4 = phosphate, PTH = parathyroid hormone.
- Table 2:
“Sick-day” medications that should be held in patients who have an acute illness with risk of hypotension and acute kidney injury
Class Examples Angiotensin-converting enzyme inhibitors Perindopril, ramipril, lisinopril Angiotensin receptor blockers Candesartan, telmisartan, irbesartan Aldosterone antagonists Spironolactone, eplerenone Sodium–glucose cotransporter 2 inhibitors Empagliflozin, dapagliflozin, canagliflozin Diuretics Thiazides: indapamide, hydrochlorothiazide
Loop diuretics: furosemideNSAIDs Naproxen, ibuprofen, diclofenac Biguanide antidiabetic agent Metformin Sulfonylureas Glyburide, gliclazide Direct renin inhibitors Aliskiren Note: NSAIDs = nonsteroidal anti-inflammatory drugs.
- Table 3:
Suggestions for management of symptoms related to chronic kidney disease in older adults
Symptoms Management Fatigue Optimize anemia management.
Optimize cardiac function and ensure adequate diuretic doses.
Consider dose reduction of β-blockers.
Consider an exercise program. (43)
Optimize nutrition.Dyspnea Restrict salt and fluid consumption.
Consider volume overload. Higher doses of furosemide may be required as GFR drops.
Optimize anemia management.Pain Avoid oral NSAIDs. Topical agents may be used with caution.
Acetaminophen may have limited efficacy.
Neuropathic agents such as gabapentinoids (start gabapentin at 100 mg orally daily). Monitor for fall risk.
Opioids may be used for unremitting pain. Hydromorphone is the preferred opioid (start with 0.5 to 1 mg orally every 4–6 h, as necessary).
There is limited evidence for cannabinoid use in CKD.Nausea Treat constipation.
Large meals and strong smells may be triggering.
Metoclopramide (2.5 mg orally every 4 h, as necessary) and ondansetron (4–8 mg orally every 8 h, as necessary). (43)
Atypical antipsychotics such as olanzapine (2.5 mg orally every 4 h, as necessary) or low-dose haloperidol (0.5 mg orally every 4 h, as necessary) can be beneficial. (43)Pruritus Thick emollients should be first line for symptomatic relief.
Patients should avoid hot showers or baths as they may exacerbate dryness of skin.
Topical agents include camphor and menthol-based compounds and low-potency steroids. Capsaicin-based creams may be effective.
Gabapentinoids and SSRIs at low doses may be helpful.
Antihistamines should be avoided, but hydroxyzine may be used with caution (10 mg twice per day, as necessary).
Ultraviolet-B therapy may be used (poor evidence). (43)Sleep disturbance Nonpharmacologic therapies include exercise, reducing caffeine and limiting fluid intake in the evening.
Diuretics should be dosed earlier in the day (e.g., second dose of furosemide no later than 2 pm).
Treat benign prostatic hyperplasia where applicable.
Treat pain, restless leg syndrome and pruritus.
Consider melatonin (initiate at 3 mg at night) and mirtazapine (initiate at 3.75 mg to 7.5 mg at night).Restless leg syndrome or cramping or both Manage modifiable factors such as iron deficiency and use of antidepressants and dopamine antagonists. (43)
Low-dose magnesium supplementation may be beneficial.
Gabapentinoids (start gabapentin 100 mg orally at night and titrate up).
Consider dopamine agonists such as pramipexole (0.125–0.25 mg orally three times daily, as necessary) or ropinirole (starting dose 0.25 mg/d). (43)Depression Manage contributing symptoms (e.g., pain, insomnia, pruritus). (43)
Optimize social supports.
Nonpharmacologic interventions include cognitive behaviour therapy and exercise. (43)
Dose-adjusted antidepressants such as mirtazapine may be effective.Note: CKD = chronic kidney disease, GFR = glomerular filtration rate, NSAID = nonsteroidal anti-inflammatory drug, SSRI = selective serotonin reuptake inhibitor.