Guidelines & Protocols Advisory Committee

Chronic Kidney Disease in Adults – Identification, Evaluation and Management

Effective Date: October 30, 2019

Scope
This guideline provides recommendations for the investigation, evaluation, and management of adults at risk of or with known
chronic kidney disease (CKD). These recommendations and treatment targets may not be appropriate in all cases because
many patients with CKD are complex due to older age and comorbidities. Communication between primary care providers and
specialists is strongly encouraged.

Key Recommendations
• Identify high-risk patient groups for evaluation of CKD: diabetes, hypertension, cardiovascular disease, family history,
high risk ethnicity (Indigenous peoples, Pacific Islanders, African, Asian, and South Asian descent), history of acute kidney
injury (AKI).
• Screen high-risk patients using eGFR and uACR. Confirm abnormal test results with a repeat measurement and obtain
urinalysis.
• Determine likely cause of kidney disease where possible. The cause of CKD has important implications for the risk of end
stage renal disease (ESRD) and other complications.
• The three dimensions of Cause, eGFR and Albuminuria (CGA) are all important in developing a management plan.
• Prompt advice from local internists, local nephrologists or the RACE Line is available to assist in determining the need for
and timing of referral.

Figure 1. Prognosis and recommendations for frequency of monitoring based on eGFR and uACR*
Albuminuria (ACR) Categories
A1 A2 A3
<3 mg/mmol 3-30 mg/mmol >30 mg/mmol
G1 >90
eGFR Categories

G2 60-89
Low risk
G3a 45-59 Very high risk
Moderate risk
G3b 30-44 Test 3 times per year
Test annually
G4 15-29
High risk
G5 <15 Test 4 times per year
Test 2 times per year

* Adapted from ckdpathway.ca and Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2012 Clinical Practice Guideline for the
Evaluation and Management of Chronic Kidney Disease. Kidney inter., Suppl. 2013;3:1–150
Background
CKD is associated with other common chronic
diseases such as diabetes, hypertension, and
cardiovascular disease (CVD)1 and an estimated
1:10 British Columbians has some form of Age Standardized Rate Per 100
significant kidney disease.2
<= 2.00
CKD markedly increases the risk of: cardiovascular 2.01 - 2.20
disease, adverse drug reactions, acute kidney injury 2.21 - 2.40
2.41 - 2.60
and prolonged hospital admissions. 4–10, 13–14 Patients
2.61 - 2.80
with CKD have a risk of progression to end stage 2.81 - 3.00
renal disease (ESRD), often requiring dialysis or
kidney transplantation. 6, 9, 11–14 Most patients with
chronic kidney disease die from other comorbidities
before they progress to kidney failure. The outcome
of many patients who go on to dialysis remains
poor with 10 percent annual mortality; the
overall 5 year survival rate is worse than that of
most cancers.3
Evidence clearly indicates that control of
hypertension and proteinuria can prevent or
postpone kidney function decline.4 –12 This
underscores the importance of early detection,
evaluation and management of individuals Figure 2. CKD prevalence by health service delivery area 2017/2018.
with kidney disease.

Definition
CKD is defined as an abnormality of kidney structure or function that is present for greater than 3 months.13
The two key parameters for classification are estimated glomerular filtration rate (eGFR) and urine albumin to creatinine
ratio (uACR). eGFR is the best marker for kidney function and is calculated from creatinine. All labs in British Columbia (BC)
automatically report eGFR when creatinine is ordered. Note: the recommended equations for eGFR may change over time
and are estimates only. Refer to page 3 for more information.
For diagnostic purposes, other evidence of kidney damage includes: urine abnormalities such as hematuria; structural problems
on imaging studies e.g., polycystic kidneys on ultrasound; histological findings on kidney biopsy.

Etiology
The two most common causes of CKD are hypertension and diabetes and they often co-exist.13 Even if the cause seems obvious
(e.g., diabetes), the possibility of a serious underlying primary renal disorder (e.g., glomerulonephritis) must be considered in
patients with:
• Abnormal urinalysis, (e.g., proteinuria, hematuria, cellular casts). Note: hyaline casts are normal.
• Rapid sustained decline in kidney function (change in eGFR > 10-15%/year) despite remedy of reversible precipitants
(e.g., volume contraction, febrile illness, medications).
• Constitutional symptoms suggesting systemic illness.
• Sudden or severe onset of symptoms (e.g., edema unrelated to heart or liver disease).

2 BCGuidelines.ca: Chronic Kidney Disease in Adults – Identification, Evaluation and Management

Risk Factors and Screening

The following populations are at increased risk for CKD At-risk populations should be screened every 1–2 years
and should be screened: depending upon clinical circumstances (e.g., annually
• Diabetes for individuals with diabetes) using:
• Hypertension • eGFR
• Cardiovascular disease (CVD) • urinalysis (dipstick)*
• Prior acute kidney injury (AKI) • urine ACR
• Family history of kidney disease (e.g., parent or sibling) • review of risk factors
• Specific high-risk ethnic groups: Indigenous peoples, *Note: urine microscopy is not needed for screening.
Pacific Islanders, African Asian, and South Asian descent
Note: Older age alone is not a reason for screening.

Diagnosis
CKD cannot be diagnosed with one isolated abnormal measurement of eGFR or urine ACR.

Estimated GFR (eGFR) Values and Interpretation

• Values of > 60 mL/min per 1.73m2 without other markers of kidney disease (albuminuria, hematuria, structural
abnormalities) do not indicate CKD.
• Values of < 60 mL/min per 1.73m2 which are persistent (present for ≥ 3 months) are diagnostic of CKD.
• A single isolated measurement < 60 mL/min does not satisfy diagnostic criteria for CKD, but could reflect reduced kidney
function and requires confirmatory testing.
• In patients with a new unexpected finding of reduced eGFR, the test should be repeated to establish stability or
rapid deterioration.
Caveats of eGFR
o eGFR is an estimated value that assumes a steady state of creatinine generation.
o eGFR may be unreliable in extremes of muscle mass or with certain diets (e.g., very high or very low protein). Some
medications can interfere with the excretion of creatinine (e.g., trimethoprim, fenofibrate).14, 15
o In hospitalized patients or patients with AKI the fluctuations in creatinine make eGFR unreliable. In these
circumstances, creatinine values should be used to guide management.
o As a general rule, the eGFR can be used as a guide to outpatient drug dosing, even if the references use creatinine
clearance (eCrCl). More caution is required for drugs with significant potential toxicity or a narrow therapeutic window
(e.g., chemotherapy).
Urinalysis and ACR Values and Interpretation
• Significant abnormalities include persistent white blood cells or red blood cells in the absence of infection or
instrumentation, and the presence of cellular casts.
• Urine ACR (uACR) is the preferred method to screen for protein in the urine.
o uACR quantifies albuminuria in a range which is not detected by dipstick urinalysis.
o The term microalbumin has historically been used. Recent guidelines and consensus from laboratories have
recommended abandoning this term and to quote the uACR value instead.13
o uACR elevation (>3.0 mg/mmol) on serial testing is abnormal.
o In patients without diabetes, no specific treatment is recommended for isolated uACR values between
3 and 30 mg/mmol. These individuals remain at risk of CKD progression and cardiovascular disease, therefore
surveillance is warranted.
o uACR may be unreliable in some patients due to acute illness, vigorous exercise, poorly controlled hypertension or
poorly controlled blood glucose. Repeat testing should be done when in doubt.

3 BCGuidelines.ca: Chronic Kidney Disease in Adults – Identification, Evaluation and Management

 • Urine test abnormalities, even with persistent eGFR values ≥ 60 mL /min per 1.73m2 suggest kidney disease.
• 24-hour urine collections are not necessary in most cases.
• For equivalence of dipstick protein measurements, uACR and protein/creatinine ratios (PCR), see Appendix.

Renal Imaging
• Renal ultrasound should be undertaken to assess structural abnormalities and aid in diagnosis. Renal ultrasound should
be performed in the following cases:
o Obstructive urinary symptoms
o Unexplained microscopic or macroscopic hematuria
o Unclear etiology of CKD, especially in young patients
o Patients with suspicion of benign prostatic hypertrophy (BPH)
o Family history of structural renal disease (e.g., cystic kidney disease)

Staging of CKD
Risk staging of kidney disease is important for care planning and patient management. Risk is determined based on Cause, eGFR,
and uACR, or CGA. Refer to Figure 1 (page 1). Further details on risk determination are available on the Kidney Disease Improving
Global Outcomes (KDIGO) CKD management guideline at kdigo.org/home/guidelines.13

Risk Calculators
The Kidney Failure Risk Equation (KFRE) is an equation designed to estimate probability of requiring dialysis within 2 or 5 years.
The equation is derived from 4 variables and can be calculated using QxMD: qxmd.com. Risks of > 10 – 20% indicate high risk
(analogous to Framingham risk scores). The KFRE is a useful tool for prognostication, however its role has yet to be established in
routine clinical practice.

Referral Recommendations
Indications for referral to specialist/nephrologist 22†
Very high risk kidney disease (urgent communication needed)
• Presence of active urine sediments (red blood cell casts or cellular casts ± protein), especially when associated with
reduced eGFR.
• AKI in absence of readily reversible cause (e.g., volume depletion, NSAIDs)
• Abrupt sustained fall in eGFR in a patient with known CKD.
• eGFR < 15
• Nephrotic syndrome
High risk kidney disease (patient to be seen within a timely fashion)
• GFR < 30†
• Unexplained persistent uACR >30 mg/mmol (regardless of eGFR) e.g., in absence of diabetes or HTN
• Progressive CKD, with eGFR decline > 5 ml/min/year†
• Diabetes and evidence of CKD with eGFR <45, urine ACR >30
Low to moderate risk kidney disease (patients that could be seen within a longer time interval, e.g., within 6 mos)
• Persistent abnormalities of serum potassium.
• Hereditary kidney disease.
• CKD, eGFR 30-45
• CKD and difficult to treat hypertension

Time to first consultation will vary based on individual circumstances. Discussion with your local nephrologist as to timing of referral for specific individuals
†

is encouraged if in doubt.

4 BCGuidelines.ca: Chronic Kidney Disease in Adults – Identification, Evaluation and Management

 Recommended history and tests to include in referral package:
• Comorbidities (especially cardiovascular)
• Medications
• Complete blood count (CBC)
• Electrolytes (Na, K, Cl, HCO3), calcium
• Creatinine/eGFR (include current value and any historical values available)
• Urinalysis (urine microscopy)
• Urine ACR
• If older than age 40: serum protein electrophoresis (SPEP), urine protein electrophoresis (UPEP)
• Renal ultrasound – not required prior to referral, but should be arranged with result sent to specialist when completed
Please use for referral:
• Use Pathways to see the list of specialists in your region and their wait times.
• Use the BC Renal website to locate nephrologist in your region: bcrenalagency.ca/kidney-services
• Real-time communication with local specialists (or RACE line if uncertain) can provide rapid advice for urgent cases and
facilitate the most appropriate mechanism of referral.
• Patients benefit from inclusion in multidisciplinary clinics for prevention, education and management, including by
telehealth.16–18
A urology consult is more appropriate than nephrology in the following scenarios:
• Renal mass, enlarged prostate, obstruction, and large symptomatic or obstructing kidney stone

5 BCGuidelines.ca: Chronic Kidney Disease in Adults – Identification, Evaluation and Management

Management
Refer to Figure 1 (page 1) for recommended follow-up intervals.

Customization of management plan

• Many patients with CKD have multiple comorbidities. In some situations, universal fixed targets may not be applicable and
may even be harmful. Clinical judgment and individualized targets are recommended.
• Communication with specialists is encouraged if appropriateness of any of the targets is in question.

Table 2. Care objectives and targets for CKD

Domain Recommendations Comments
Avoidance of • Strongly consider holding ACEI, ARB, SGLT-2, and diuretics if patient receiving dye, has acute AKI is defined as an increase in creatinine by
acute kidney illness with dehydration, or is having surgery (see Table in Appendix) >26µmol/L or 1.5 times baseline
injury • If contrast dye (especially arterial) is required, the risk can be mitigated with pre-hydration, Transient insults to the kidney may result in a
please talk to a nephrologist or use a published protocol. Creatinine should be measured pre change in trajectory of stable kidney function
and post procedure (within 3 days). The above medications can be restarted safely if there is Risk of contrast-induced AKI is higher in people
no evidence of AKI. with volume depletion

Medications • In CKD, some medications need to be used with caution or dose-adjusted for the level of Drug interactions are common in CKD and are
eGFR (see Appendix) avoidable
• Medication review is critical both during and after an episode of AKI.
• If hospitalized or changing serum creatinine, seek additional advice re drug dosing
• Refer to BC Renal Agency Pharmacy & Formulary information
Kidney function • Refer to Figure 1 for frequency of eGFR and uACR measurements in specific risk categories.
measurements • Repeat eGFR sooner (within 10 days) after any change in medications (e.g., ACEi, ARB, or
diuretics, SGLT2i), medical intervention, or hospitalization.
• Check creatinine and potassium prior to starting ACEi, ARB, SGLT2i, MRA within 7–14 days
of starting, and within 7–14 days after a dose increase.
• Creatinine rise >20% after dose increase should be followed by further measurements
within 7–14 days.
Blood pressure • ACE or ARB is generally first line therapy in proteinuric kidney disease BP targets are continually changing.
• Measure and record BP at diagnosis and at every visit thereafter. Use clinical judgment when interpreting BP
See BC guideline: Hypertension – Diagnosis and Management targets. Consider comorbidities and prognosis.
• Ambulatory BP monitoring is encouraged
• In general, a BP <140/90mmHg is appropriate. A lower target
(< 130/80) should be sought in patients with diabetes or CKD with significant proteinuria
• Consultation with a specialist colleague is recommended for complex patients, especially
elderly patients with multiple comorbidities.
CVD risk • Calculate & record CVD risk. See BC guideline: Cardiovascular Disease – Primary Prevention After LDL reduction achieved, regular
assessment • Manage in accordance with relevant guidelines. See CCS Guidelines for the Management of monitoring of lipids may not be necessary
Dyslipidemia for the Prevention of Cardiovascular Disease in the Adult.
• Check lipids once to establish baseline and after therapy x 1.
• Consider use of statins and lipid lowering strategies irrespective
of LDL levels.
Diabetes • ACE or ARB is generally first line therapy in proteinuric kidney disease HbA1C: ≤ 7.0% may not be appropriate for
• Long-acting sulfonylureas are associated with hypoglycemia and are not recommended older frail patients
• SGLT-2 inhibitors improve glycemic control and reduce the risks of CVD and CKD progression See BC Guideline: Diabetes Care
in patients with diabetes and chronic kidney disease 23 Risk/benefit of metformin can be challenging
• In those with unstable eGFR or acute changes in clinical condition, metformin should be and requires discussion with a specialist
held, dose-reduced or avoided (see Table in Appendix)
Conditions • Measure at least annually: Target hemoglobin is lower than the normal
associated o CBC and iron profiles (percent iron saturation). range for patients on ESA therapy (95- 115 g/L)
with CKD o Mineral metabolism (calcium, phosphorus). Iron saturation <20% indicates iron depletion.
o Albumin Ferritin is not a reliable test in CKD patients
o If questions about any abnormalities feel free to contact specialist colleagues. and should not be ordered to assess iron
deficiency.

Vaccinations • Influenza vaccine annually. Patients with very advanced CKD are less likely
• Pneumococcal and Hepatitis B vaccines recommended for adults at medically high risk. to seroconvert after hepatitis B immunization.
• Refer to immunizebc.ca for other recommended vaccines by age and Confirmation of immunity is required after
risk profile vaccination, which may need to be repeated
(after consultation with specialist)

6 BCGuidelines.ca: Chronic Kidney Disease in Adults – Identification, Evaluation and Management

Lifestyle and Self-Management
Support patient self management with the means available in your community. Patients with CKD benefit from multidisciplinary
renal teams who can support patients to make beneficial changes in diet, smoking and physical activity, and to understand
medications, and the uncertainty and emotional distress that can be seen in those with chronic conditions. Denial, often
associated with grief, is common in patients with chronic disease affecting a vital organ.

Encourage patients with CKD to consider advance care planning and their goals for future care, including for the end of life.
o Provincial advance care planning resources are available at gov.bc.ca/advancecare
o BC Guidelines on palliative care are available at bcguidelines.ca/submenu_palliative.html
o BC Renal Agency information about end of life care is available at bcrenalagency.ca/healthcare-professionals/end-life-
resources

Complex Scenarios
The following common complex scenarios benefit from discussion with a specialist:

• Whether to change the approach to a patient when eGFR goes down to 30 or lower
o Example: A 60 year old woman with type 2 diabetes mellitus has a change in eGFR from 32 to 29. Should her metformin
be stopped?
• Deciding whether to stop diuretic therapy when the creatinine goes up or eGFR goes down
o Example: A 70 year old man with congestive heart failure requires escalation of diuretic therapy and experiences a
deterioration in creatinine. Should his diuretics be discontinued?
• Difficult-to-treat hypertension
• Anticoagulation in patients with CKD

Abbreviations
• AKI: acute kidney injury
• CKD: chronic kidney disease
• CVD: cardiovascular disease
• eGFR: estimated glomerular filtration rate
• ESRD: end stage renal disease
• uACR: urine albumin to creatinine ratio
Resources
Diagnostic code: 585 (chronic renal failure)

Associated Documents
• Chronic Kidney Disease Flow Sheet
Appendices
• Appendix A: Potential complications of CKD
• Appendix B: Interpretation of urine ACR values to assess albuminuria and proteinuria
• Appendix C: Recommended drug modifications in presence of acute kidney injury (AKI)
Practitioner Resources
• BC Renal Agency – bcrenalagency.ca
Clinical resources for physicians, dieticians, pharmacists and information for patients.
• Chronic Kidney Disease Clinical Web/Mobile Tool: algorithm for CKD patient care

7 BCGuidelines.ca: Chronic Kidney Disease in Adults – Identification, Evaluation and Management

 • RACE: Rapid Access to Consultative Expertise Program – raceconnect.ca
A telephone consultation line for select specialty services for physicians, nurse practitioners and medical residents. If the
relevant specialty area is available through your local RACE line, please contact them first. Contact your local RACE
line for the list of available specialty areas. Currently in BC, regions providing Nephrology services include Vancouver (VCH/
PHC), Fraser and Northern. Regions that don’t currently have RACE support for Nephrology are Interior and South Island. If
your local RACE line does not cover the relevant specialty service or there is no local RACE line in your area, please contact
the Vancouver Coastal Health Region/Providence Health Care RACE line.
o VCH Region/Providence Health Care: ☎ 604-696-2131 or 1-877-696-2131 (toll free)
o Northern RACE: ☎ 1-877-605-7223 (toll free)
o Fraser Valley RACE: raceapp.ca
• Pathways – PathwaysBC.ca
An online resource that allows GPs and nurse practitioners and their office staff to quickly access current and accurate
referral information, including wait times and areas of expertise, for specialists and specialty clinics. In addition, Pathways
makes available hundreds of patient and provider resources that are categorized and searchable.
• HealthLink BC: healthlinkbc.ca
HealthLink BC provides reliable non-emergency health information and advice to patients in BC. Information and advice
on managing chronic kidney disease in several languages is available by telephone, website, a mobile app and a collection
of print resources. Patients can speak to a health services navigator, registered dietitian, registered nurse, qualified exercise
professional, or a pharmacist.
Patients may call 8-1-1 toll-free in B.C., or for the deaf and the hard of hearing, call 7-1-1.
• Health Data Coalition: hdcbc.ca
An online, physician-led data sharing platform that can assist you in assessing your own practice in areas such as chronic
disease management or medication prescribing. HDC data can graphically represent patients in your practice with chronic
kidney disease in a clear and simple fashion, allowing for reflection on practice and tracking improvements over time.
References
1. Eckardt K-U, Coresh J, Devuyst O, Johnson RJ, Köttgen A, Levey AS, et al. Evolving importance of kidney disease: from subspecialty to global health burden. Lancet Lond
Engl. 2013 Jul 13;382(9887):158–69.
2. BC Renal Agency. Chances of having kidney disease estimated one in ten [Internet]. [cited 2014 Jun 12]. Available from: www.bcrenalagency.ca/news/chances-having-
kidney-disease-estimated-one-10
3. Canadian Institute for Health Information. CORR reports – treatment of end-stage organ failure in Canada 2001- 2010 (2011-12 Annual Report) [Internet]. [cited 2014
Jun 12]. Available from: //secure.cihi.ca/free_products/2011_CORR_Annua_Report_EN.pdf
4. Trivedi HS, Pang MMH, Campbell A, Saab P. Slowing the progression of chronic renal failure: economic benefits and patients’ perspectives. Am J Kidney Dis Off J Natl
Kidney Found. 2002 Apr;39(4):721–9.
5. Snyder JJ, Collins AJ. Association of preventive health care with atherosclerotic heart disease and mortality in CKD. J Am Soc Nephrol JASN. 2009 Jul;20(7):1614–22.
6. Diabetes Control and Complications Trial Research Group, Nathan DM, Genuth S, Lachin J, Cleary P, Crofford O, et al. The effect of intensive treatment of diabetes on the
development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993 30;329(14):977–86.
7. Klahr S, Levey AS, Beck GJ, Caggiula AW, Hunsicker L, Kusek JW, et al. The effects of dietary protein restriction and blood-pressure control on the progression of chronic
renal disease. Modification of Diet in Renal Disease Study Group. N Engl J Med. 1994 Mar 31;330(13):877–84.
8. Effect of intensive therapy on the development and progression of diabetic nephropathy in the Diabetes Control and Complications Trial. The Diabetes Control and
Complications (DCCT) Research Group. Kidney Int. 1995 Jun;47(6):1703–20.
9. Anderson S, Halter JB, Hazzard WR, Himmelfarb J, Horne FM, Kaysen GA, et al. Prediction, progression, and outcomes of chronic kidney disease in older adults. J Am Soc
Nephrol JASN. 2009 Jun;20(6):1199–209.
10. Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: results of the HOPE study and MICRO-HOPE substudy. Heart
Outcomes Prevention Evaluation Study Investigators. Lancet Lond Engl. 2000 Jan 22;355(9200):253–9.
11. Brenner BM, Cooper ME, de Zeeuw D, Keane WF, Mitch WE, Parving HH, et al. Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes
and nephropathy. N Engl J Med. 2001 Sep 20;345(12):861–9.
12. ACE Inhibitors in Diabetic Nephropathy Trialist Group. Should all patients with type 1 diabetes mellitus and microalbuminuria receive angiotensin-converting enzyme
inhibitors? A meta-analysis of individual patient data. Ann Intern Med. 2001 Mar 6;134(5):370–9.
13. Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney
Disease. Kidney Int. Suppl. 2013(3):1–150.
14. Paige NM, Nagami GT. The top 10 things nephrologists wish every primary care physician knew. Mayo Clin Proc. 2009 Feb;84(2):180–6.
15. Shimada M, Dass B, Ejaz A. Assessment of elevated creatinine [Internet].
Available from: http://bestpractice.bmj.com/best-practice/monograph/935/overview/aetiology.html
16. Goldstein M, Yassa T, Dacouris N, McFarlane P. Multidisciplinary predialysis care and morbidity and mortality of patients on dialysis. Am J Kidney Dis Off J Natl Kidney
Found. 2004 Oct;44(4):706–14.
17. Curtis BM, Ravani P, Malberti F, Kennett F, Taylor PA, Djurdjev O, et al. The short- and long-term impact of multi-disciplinary clinics in addition to standard nephrology
care on patient outcomes. Nephrol Dial Transplant Off Publ Eur Dial Transpl Assoc - Eur Ren Assoc. 2005 Jan;20(1):147–54.

8 BCGuidelines.ca: Chronic Kidney Disease in Adults – Identification, Evaluation and Management

 18. Hemmelgarn BR, Manns BJ, Zhang J, Tonelli M, Klarenbach S, Walsh M, et al. Association between multidisciplinary care and survival for elderly patients with chronic
kidney disease. J Am Soc Nephrol JASN. 2007 Mar;18(3):993–9.
19. Owen RJ, Hiremath S, Myers A, Fraser-Hill M, Barrett BJ. Canadian Association of Radiologists consensus guidelines for the prevention of contrast-induced nephropathy:
update 2012. Can Assoc Radiol J J Assoc Can Radiol. 2014 May;65(2):96–105.
20. Komenda P, Zalunardo N, Burnett S, Love J, Buller C, Taylor P, et al. Conservative outpatient renoprotective protocol in patients with low GFR undergoing contrast
angiography: a case series. Clin Exp Nephrol. 2007 Sep;11(3):209–13.
21. Schachter ME, Romann A, Djurdev O, Levin A, Beaulieu M. The British Columbia Nephrologists’ Access Study (BCNAS) - a prospective, health services interventional
study to develop waiting time benchmarks and reduce wait times for out-patient nephrology consultations. BMC Nephrol 2013 Aug 29;14:182-2369-14-182.
22. KCC Guidelines: bcrenalagency.ca/resource-gallery/Documents/KCC%20phases.pdf
23. Perkovic V, Jardine MJ, Neal B, Bompoint S, Heerspink HJ, Charytan DM, Edwards R, Agarwal R, Bakris G, Bull S, Cannon CP. Canagliflozin and renal outcomes in type 2
diabetes and nephropathy. New England Journal of Medicine. 2019 Jun 13;380(24):2295-306.

This guideline is based on scientific evidence current as of the effective date.

The guideline was developed by the Guidelines and Protocols Advisory Committee in collaboration and adopted by
the Medical Services Commission.

For more information about how BC Guidelines are developed, refer to the GPAC Handbook available at
BCGuidelines.ca: GPAC Handbook.

THE GUIDELINES AND PROTOCOLS ADVISORY COMMITTEE

The principles of the Guidelines and Protocols Advisory Committee are to:
• encourage appropriate responses to common medical situations
• recommend actions that are sufficient and efficient, neither excessive nor deficient
• permit exceptions when justified by clinical circumstances

Contact Information:
Guidelines and Protocols Advisory Committee
PO Box 9642 STN PROV GOVT
Victoria BC V8W 9P1
Email: hlth.guidelines@gov.bc.ca
Website: www.BCGuidelines.ca

Disclaimer
The Clinical Practice Guidelines (the “Guidelines”) have been developed by the Guidelines and
Protocols Advisory Committee on behalf of the Medical Services Commission. The Guidelines
are intended to give an understanding of a clinical problem, and outline one or more preferred
approaches to the investigation and management of the problem. The Guidelines are not
intended as a substitute for the advice or professional judgment of a health care professional,
nor are they intended to be the only approach to the management of clinical problem. We
cannot respond to patients or patient advocates requesting advice on issues related to
medical conditions. If you need medical advice, please contact a health care professional.

9 BCGuidelines.ca: Chronic Kidney Disease in Adults – Identification, Evaluation and Management

 Guidelines & Protocols Advisory Committee

Appendix A: Potential Complications of CKD*

Potential Complications of CKD1 (listed alphabetically)
• Acute Kidney Injury • Hyperkalemia
(e.g., dehydration, contrast dye, drugs) • Hyperparathyroidism
• Anemia • Hyperphosphatemia
• Hypertension • Hyperuricemia
• Calcium absorption decreases • Left ventricular hypertrophy
• Drug toxicity • Malnutrition potential (late)
• Dyslipidemia • Metabolic acidosis
• Heart failure/volume overload

* Listed complications are not specific to CKD but tend to occur with increasing frequency and are more directly attributable to more severe reduction in kidney
function. If complications are noted at an early stage of CKD, investigation of alternative causes is recommended (e.g., profound anemia at eGFR of 55 mLl/min is
likely not attributable to low kidney function alone). Kidney damage is defined as pathological abnormalities (e.g., kidney biopsy results) or markers of damage
including abnormalities in blood or urine tests (e.g., protein/albumin in the urine, red blood cells, white blood cells or casts) or imaging studies.13

Appendix B: Interpretation of urine ACR values to assess

albuminuria and proteinuria
Categories uACR (mg/mmol) Protein reagent strip PCR (mg/mmol)
Normal to mildly increased < 3.0 Negative to trace < 15.0

Moderately increased 3.0 – 30.0 Trace to + 15.0 – 50.0

Severely increased > 30.0 + or greater > 50.0

10 BCGuidelines.ca: Chronic Kidney Disease in Adults – Identification, Evaluation and Management – Appendix A
 Guidelines & Protocols Advisory Committee

Appendix C: Recommended drug modifications in presence of CKD

and in acute kidney injury (AKI)*
This list is not inclusive and only provides some examples of drugs that require adjustment in CKD and AKI. Primary care
practitioners should consult a specialist or pharmacist for more information about specific medication questions.
Medication Pathophysiology Recommendation in CKD Hold in AKI?
NSAIDS Decreases renal perfusion, Interstitial nephritis Use with caution in CKD. Yes
ACEI, ARB, or any medication Protective in proteinuric CKD, diabetes, and heart failure but ACEI or ARB should be held in hypovolemia, and if receiving IV Yes
containing those compounds can cause decreased renal perfusion and hyperkalemia contrast.

Potassium sparing diuretics Volume depletion and hyperkalemia In CKD (other than in AKI), dose and frequent monitoring is Yes
(spironolactone, eplerenone, essential if eGFR < 50 mL/min.
and amiloride)
Metformin Increased risk of metformin associated lactic acidosis (MALA) Avoid if GFR <30 Yes
SGLT-2 Inhibitors Protective in diabetic nephropathy and cardiovascular disease Hold temporarily in the setting of volume depletion, or prior to Yes
but can cause decreased renal perfusion in the setting of administering contrast dye.
volume depletion
Diuretics: furosemide and Volume depletion and electrolyte abnormalities N/A Yes, unless
thiazides volume
overloaded
Opioids Metabolites can accumulate Reduce dose in CKD Consider dose
(e.g., hydromorphone, For opioids that are considered safer in CKD, and opioids to reduction
fentanyl, methadone (for avoid in CKD, consult:
pain), oxycodone) bcrenalagency.ca/resource-gallery/Documents/Preferred-
Medications.pdf
Pregabalin and gabapentin Accumulation Reduce dose and monitor for adverse effects Consider dose
In severe renal failure, dose should not exceed 300 mg reduction
gabapentin per day.
Digoxin Hyperkalemia Reduce dose in CKD and monitor potassium and drug levels. Adjust dose
Accumulation with side effects (bradycardia, confusion) Consider alternative therapy in the setting of renal failure.
Acyclovir Risk of crystal nephropathy Encourage hydration. Dose adjust for GFR No.
Drug accumulation and side effects (risk of seizures/confusion) Ensure hydration.
Statins Risk of rhabdomyolysis Consider dose reduction in CKD. Hold if rhabdomyolysis or No
unexplained/persistent muscle pain.
Phenytoin Risk of accumulation and toxicity Monitor levels and also adjust level for serum albumin No
Lithium Accumulation and increased risk of side effects Monitor lithium and electrolyte levels No
Risk of nephrogenic diabetes insipidus Encourage hydration
Risk of chronic interstitial nephritis Refer to a nephrologist if eGFR declines.
Hypoglycemics Accumulation can increase risk of hypoglycaemia Avoid long acting preparations in moderate-severe CKD. May No
(sulfonylureas, require dose adjustments.
insulin, meglitinides,
thiazolidinediones)
Trimethoprim and Risk of hyperkalemia Reduce dose when eGFR <30 mL/min, monitor GFR and No
co-trimoxazole Reduces tubular secretion of creatinine so leads to a rise in potassium
serum creatinine without renal injury
Colchicine Risk of accumulation and serious toxicity (GI, CNS) Use lower dose and consider other agents (e.g., Steroids) No
Proton pump inhibitors Risk of interstitial nephritis Clarify indication and consider other agent (e.g., H2 blocker) No
For more information on dosing of DOACs in kidney disease please visit the 2018 European Heart Rhythm Association Guidelines (Figure 4). Available from
academic.oup.com/eurheartj/article/39/16/1330/4942493
For more information on common prescribing questions for patients with CKD, consult:
bcrenalagency.ca/resource-gallery/Documents/CKD-Common_Prescribing_Qs_CKD_Patients_not_on_Dialysis.pdf
bcrenalagency.ca/health-professionals/clinical-resources/symptom-assessment-and-management
Further information about drug dosage adjustments in chronic kidney disease is available from:
rxfiles.ca/rxfiles/uploads/documents/ltc/HCPs/CKD/SDIS.Renal_newsletter.pdf

* Adapted from: Acute Kidney Injury – potentially problematic drugs and actions to take in primary care. “Think Kidneys” initiative by the UK Renal Registry in part-
nership with NHS England. Available from: thinkkidneys.nhs.uk/aki/wp-content/uploads/sites/2/2016/07/Primary-Care-Advice-for-medication-
review-in-AKI-.pdf

11 BCGuidelines.ca: Chronic Kidney Disease in Adults – Identification, Evaluation and Management – Appendix C