Management CKD stage 4

Management of Stage 4 CKD

  • Blood Tests (Renal Profile & FBC) 3 to 6 monthly for estimation of :
    • Creatinine and Potassium - consider an unexplained fall in eGFR of >25% to be acute renal failure. NICE suggest seeking specialist advice for a loss in GFR over 1y of 5ml/min, or a loss of GFR in 5y of 10ml/min
    • Hb - if low, exclude non-renal cause. Below 11.0 g/dl, specific therapy may be considered to improve quality of life. Hb falls progressively as GFR falls, but renal anaemia rarely becomes significant before stage 4 CKD.
    • Abnormal Calcium & Phosphate levels – high phosphate or PTH levels may need specialist input, consider referral
    • Acidosis – low bicarbonate – may need specialist input, consider referral
    • Urinary protein for ACR or PCR. Note thresholds; ACR 30 or PCR 50 for more stringent blood pressure targets, and ACR 70 or PCR 100 for  re-referral/discussion.
    • Blood pressure - 140/90 max (130-139/90), or 130/80 max (120-129/80) for patients with proteinuria: urinary ACR>30 or PCR>50
    • Cardiovascular risk - advice on smoking, exercise and lifestyle. Consider cholesterol lowering therapy if already have macro vascular disease, or if estimated 10 year risk of cardiovascular events =/>20%.
    • Immunization - influenza and pneumococcal
    • Medication review - regular review of medication to minimise nephrotoxic drugs (particularly NSAIDs) and ensure doses of others are appropriate to renal function.

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