Diabetic Kidney Disease

- Diabetic kidney disease (DKD) is a suitable umbrella term to include both diabetic nephropathy and diabetes mellitus with chronic kidney disease.
  - Diabetic nephropathy
    
    Damage to the glomerular capillaries in people with diabetes mellitus resulting in albuminuria in the absence of other causes of albuminuria.
  - Diabetes mellitus and chronic kidney disease
    
    The presence for more than 3 months of structural renal abnormalities with reduced glomerular filtration in people with diabetes mellitus.
  [ABCD and Renal association 2021]
- SELECT
- Offer annual testing for CKD using eGFR, serum creatinine and early morning urinary ACR to people with Diabetes
- Who should be tested for CKD <div class="navybox"> <p><b><u>Who should be tested for CKD</u></b></p> <ul> <li><b>Monitor GFR at least annually in adults, children and young people taking drugs known to be nephrotoxic</b>, such as calcineurin inhibitors (for example, cyclosporin or tacrolimus), lithium and non-steroidal anti-inflammatory drugs (NSAIDs). </li> <li> <details open> <summary><b>Offer testing for CKD using eGFR and ACR to adults with any of the following risk factors:</b></summary> <ul> <li>diabetes</li> <li>hypertension</li> <li>acute kidney injury</li> <li>cardiovascular disease (ischaemic heart disease, chronic heart failure, peripheral vascular disease or cerebral vascular disease)</li> <li>structural renal tract disease, recurrent renal calculi or prostatic hypertrophy</li> <li>multisystem disease with potential kidney involvement e.g. SLE</li> <li>family history of end-stage kidney disease (GFR category G5) or hereditary kidney disease</li> <li>incidental detection of haematuria or proteinuria.</li> </ul> </details> </li> <li> <details open> <summary><b>Offer testing for CKD using eGFR and ACR to children and young people with any of the following risk factors:</b></summary> <ul> <li>acute kidney injury </li> <li>solitary functioning kidney.</li> </ul> </details> </li> <li> <details> <summary>Consider testing for CKD using eGFR and ACR in children and young people with any of the following risk factors:</summary> <ul> <li>low birth weight (2,500 g or lower)</li> <li>diabetes</li> <li>hypertension</li> <li>cardiac disease</li> <li>structural renal tract disease or recurrent renal calculi</li> <li>multisystem disease with potential kidney involvement e.g. SLE</li> <li>family history of end-stage kidney disease (GFR category G5) or hereditary kidney disease</li> <li>incidental detection of haematuria or proteinuria.</li> </ul> </details> </li> <li> <details> <summary>Do not use any of the following as risk factors indicating testing for CKD in adults, children and young people:</summary> <ul> <li>age</li> <li>gender</li> <li>ethnicity</li> <li>obesity in the absence of metabolic syndrome, diabetes or hypertension. </li> </ul> </details> </li> <li><b>Monitor adults, children and young people for the development or progression of CKD for at least 3 years after acute kidney injury</b> (longer for people with acute kidney injury stage 3) even if eGFR has returned to baseline.</li> </ul> </div>
- STEP 1 → Select eGFR result
  Advise the person not to eat meat for at least 12 hours before the test
  - eGFR ≤ 60 mL/min
  - eGFR > 60 mL/min
  NICE: CKD 2021 DRAFT GUIDANCE
  - Interpret eGFR with caution in adults with extremes of muscle mass, for example, in bodybuilders, people who have had an amputation or people with muscle wasting disorders. (Reduced muscle mass will lead to overestimation and increased muscle mass to underestimation of the GFR.)
  - Advise adults not to eat any meat in the 12 hours before having a blood test for eGFR. Avoid delaying the despatch of blood samples to ensure that they are received and processed by the laboratory within 12 hours of venepuncture.
  - If GFR is greater than 90 ml/min, use an increase in serum creatinine concentration of more than 20% to infer significant reduction in kidney function.
  - Interpret eGFR values of 60 ml/min or more with caution, bearing in mind that estimates of GFR become less accurate as the true GFR increases.
  - Confirm an eGFR result of less than 60 ml/min/1.73 m2 10 in an adult not previously tested by repeating the test within 2 weeks. Allow for biological and analytical variability of serum creatinine (±5%) when interpreting changes in eGFR.
- ↓
  - If NEW finding repeat within 2 weeks (to rule out AKI)
    - If no AKI repeat the eGFR within 3 months
  - If stable repeat the eGFR within 3 months
  - NOTE Allow for biological and analytical variability of serum creatinine (±5%) when interpreting changes in eGFR.
  ↓
  
  Diagnose CKD if eGFR remain ≤ 60 mL/min
  
  ↓
  
  Classify the category of CKD
- Haematuria and managing isolated invisible haematuria <div class="navybox"> <p><b><u>Haematuria and managing isolated invisible haematuria</u></b></p> <ul> <li>Use reagent strips to test for haematuria in adults, children and young people: <ul> <li>Evaluate further for results of 1+ or higher.</li> <li>Do not use urine microscopy to confirm a positive result.</li> </ul> </li> <li>When there is the need to differentiate persistent invisible haematuria in the absence of proteinuria from transient haematuria, regard 2 out of 3 positive reagent strip tests as confirmation of persistent invisible haematuria.</li> <li>Persistent invisible haematuria, with or without proteinuria, should prompt investigation for urinary tract malignancy in appropriate age groups</li> <li>Persistent invisible haematuria in the absence of proteinuria should be followed up annually with repeat testing for haematuria (see recommendations above), proteinuria or albuminuria, GFR and blood pressure monitoring as long as the haematuria persists.</li> </ul> </div>
- STEP 2 → Select ACR result
  Arrange an early morning urine sample if a random spot urine is 3 – 70 mg/mmol
  - < 3 mg/mmol
  - 3 – 70 mg/mmol
  - > 70 mg/mmol
  - Note: do not use a urine dipstick to test for proteinuria unless it can measure albumin at low levels and expresses the result as an albumin:creatinine ratio (ACR).
  - Note: transient increases in urine ACR may be seen with menstruation, urinary tract infection (UTI), strenuous exercise, and upright posture (‘orthostatic proteinuria’).
  Source: CKS
- ↓
  - Repeat early morning ACR within 3 months
  ↓
  
  Diagnose CKD if ACR remains > 3 mg/mmol
  
  ↓
  
  Classify the category of CKD
- ↓
  - A repeat test is not needed as this indicates significant proteinuria
  ↓
  
  Diagnose CKD and classify the category of CKD
- ↓
  
  No evidence of Chronic Kidney Disease
  Rescreen in 1 year
- Classification and management of CKD – CAUTION! BASED ON DRAFT NICE CKD 2021 GUIDANCE – will be updated once final guidance is released
- Select eGFR and ACR results to show management based on CKD classification
- Select ACR category
  - < 3 mg/mmol (A1)
  - 3-30 mg/mmol (A2)
  - > 30 mg/mmol (A3)
- Select eGFR category
- eGFR categories
  - eGFR ≥ 90 (G1)
  - eGFR 60-89 (G2)
  - eGFR 45-59 (G3a)
  - eGFR 30-44 (G3b)
  - eGFR 15-29 (G4)
  - eGFR < 15 (G5)
- ↓
  
  Diabetic medication adjustment in CKD
- Metformin + eGFR ≥ 45 = Normal dosing regimen
- Metformin + eGFR 30-44 = Reduce dose to 500mg twice daily
- Metformin + eGFR < 30 = NOT RECOMMENDED
- Sulfonylureas + eGFR ≥ 60 = Normal dosing regimen
- Sulfonylureas + eGFR 30 – 59 = ↑ risk of hypoglycaemia
  Consider reducing SU dose. Gliclazide preferred as metabolised in the liver.
- Sulfonylureas + eGFR < 30 = NOT RECOMMENDED
- Pioglitazone = SAFE to use in CKD – Avoid in those on dialysis
- All DPP-4 inhibitors + eGFR ≥ 60 = Normal dosing regimen
- DPP-4 inhibitor + eGFR 45-59 = click to view reduced doses
  
  Alogliptin reduce to 12.5mg daily if eGFR < 50
  
  Linagliptin = Normal dosing regimen
  
  Saxagliptin reduce to 2.5mg daily
  
  Sitagliptin = Normal dosing regimen
  
  Vildagliptin reduce to 50mg daily if eGFR < 50
- DPP-4 inhibitor + eGFR 30-44 = click to view reduced doses
  
  Alogliptin reduce to 12.5mg daily
  
  Linagliptin = Normal dosing regimen
  
  Saxagliptin reduce to 2.5mg daily
  
  Sitagliptin reduce to 50mg daily
  
  Vildagliptin reduce to 50mg daily
- DPP-4 inhibitor + eGFR < 30 (Stage 4 and 5) click to view
  
  Alogliptin reduce to 6.25mg daily
  
  Linagliptin = Normal dosing regimen
  
  Saxagliptin reduce to 2.5mg daily – Avoid in those on dialysis
  
  Sitagliptin reduce to 25mg daily
  
  Vildagliptin reduce to 50mg daily
- SGLT-2 inhibitor + eGFR ≥ 60 = Normal dosing regimen
  
  Canagliflozin Initiate 100mg; titrate to 300 mg if required
  
  Dapagliflozin – Initiate 10mg
  
  Empagliflozin – Initiate 10mg and titrate to 25mg if required
  
  Ertugliflozin – Initiate 5mg and titrate to 15mg if required
- SGLT-2 inhibitor + eGFR 45-59 = click to view reduced doses
  
  Canagliflozin (if albuminuria < 30 mg/mmol at initiation) – Initiate or continue 100mg only and stop if eGFR < 45
  
  Canagliflozin (if albuminuria > 30 mg/mmol at initiation) – Initiate or continue 100mg only
  
  Dapagliflozin for T2DM – STOP if eGFR < 45, BUT DO NOT initiate if eGFR < 60
  
  Dapagliflozin for HFrEF – Initiate 10mg in those with HFrEF with or without T2D
  
  Dapagliflozin for CKD – UK license awaited (approved by FDA)
  
  Empagliflozin reduce dose to 10mg and STOP if eGFR < 45, BUT DO NOT initiate if eGFR < 60
  
  Ertugliflozin – STOP if eGFR < 45, BUT DO NOT initiate if eGFR < 60
- SGLT-2 inhibitor + eGFR 30-44 = click to view reduced doses
  
  Canagliflozin (if albuminuria < 30 mg/mmol at initiation) – NOT RECOMMENDED
  
  Canagliflozin (if albuminuria > 30 mg/mmol at initiation) – Initiate or continue 100mg only
  
  Dapagliflozin for T2DM – NOT RECOMMENDED
  
  Dapagliflozin for HFrEF – Initiate 10mg in those with HFrEF with or without T2D
  
  Dapagliflozin for CKD – UK license awaited (approved by FDA)
  
  Empagliflozin – NOT RECOMMENDED
  
  Ertugliflozin – NOT RECOMMENDED
- SGLT-2 inhibitor + eGFR < 30 (Stage 4 and 5) click to view
  
  Canagliflozin (if albuminuria < 30 mg/mmol at initiation) – NOT RECOMMENDED
  
  Canagliflozin (if albuminuria > 30 mg/mmol at initiation) – Stay on 100mg if already taking but do not initiate. Stop if renal replacement therapy
  
  Dapagliflozin for T2DM – NOT RECOMMENDED
  
  Dapagliflozin for HFrEF – No dose adjustment required based on renal function. Limited experience in HFrEF in patients with eGFR < 30. Consider discussion with secondary care
  
  Empagliflozin – NOT RECOMMENDED
  
  Ertugliflozin – NOT RECOMMENDED
- GLP-1 RA + eGFR ≥ 60 = Normal dosing regimen
- GLP-1 RA + eGFR 30-60 = Normal dosing regimen*
  
  *except Exanatide bid – Dose escalation should proceed conservatively if CrCl 30-50ml/min
- GLP-1 RA + eGFR 15-29 click to view
  
  Dulaglutide qw – No dose adjustment required
  
  Exanatide qw or bid – NOT RECOMMENDED
  
  Liraglutide od – No dose adjustment required
  
  Lixisenatide od – NOT RECOMMENDED
  
  Semaglutide s/c qw – No dose adjustment required but limited experience in patients with eGFR < 30
  
  Semaglutide oral od – No dose adjustment required but limited experience in patients with eGFR < 30
- All GLP-1 RA + eGFR < 15 = NOT RECOMMENDED
- Insulins + eGFR ≥ 60 = Normal dosing regimen
- Insulins + eGFR < 60 (Stages 3-5) – ↑ risk of hypoglycaemia
  Intensify glucose monitoring & dose adjust on an individual basis as increased risk of hypoglycaemia
- No CKD in the abscence of markers of kidney damage <div class="navybox"> <p><b><u>Markers of kidney disease which may be present include:</u></b></p> <ul> <li>Proteinuria</li> <li>Haematuria (of presumed or proven renal origin)</li> <li>Structural abnormalities (e.g. reflux nephropathy, renal dysgenesis, medullary sponge kidney)</li> <li>A known diagnosis of a genetic kidney disease (e.g. polycystic kidney disease)</li> <li>Abnormalities detected by examination of renal histology</li> <li>Electrolyte abnormalities due to renal tubular disorders</li> <li>History of kidney transplantation</li> </ul> </div>
- CKD G1A2 – Moderate risk – monitor <div class="navybox"> <p><b>Frequency of monitoring</b></p> <ul> <li>Agree the frequency of monitoring (eGFR and ACR) with patients (and their family members or carers, as appropriate), bearing in mind that CKD is not progressive in many people.</li> <li>The minimum frequency of eGFR monitoring is mentioned, but tailor it according to: <ul> <li>the underlying cause of CKD</li> <li>the rate of decline in eGFR or increase in ACR (but be aware that CKD progression is often non-linear)</li> <li>other risk factors, including heart failure, diabetes and hypertension</li> <li>changes to their treatment (such as renin–angiotensin–aldosterone system [RAAS] antagonists, NSAIDs and diuretics)</li> <li>intercurrent illness</li> <li>whether they have chosen conservative management of CKD.</li> </ul> </li> </ul> </div> once a year
  - Lifestyle Advice^{NICE CKD DRAFT 2021}
    - Encourage adults with CKD to take exercise, achieve a healthy weight and stop smoking.
    - Do not offer low-protein diets (dietary protein intake < 0.6 to 0.8 g/kg/day) to adults with CKD.
  - Risk assessment^{NICE CKD DRAFT 2021}
    - Give information about patients absolute risk and their 5-year risk of needing renal replacement therapy <div class="navybox"> <ul> <li>The draft NICE guidance suggests <a href="https://www.nice.org.uk/guidance/gid-ng10118/documents/draft-guideline#page=49" target="_blank">4-variable Kidney Failure Risk Equation</a></li> <li>Here is a more intuitive calculator (NOT FROM NICE GUIDANCE): <a href="https://kidneyfailurerisk.com/" target="_blank">kidneyfailurerisk.com</a></li> </ul> </div>
  - BLOOD PRESSSURE CONTROL^{NICE CKD DRAFT 2021}
    - Aim for BP < 140/90 <div class="navybox"> <ul> <li><b>NICE DRAFT 2021</b> <ul> <li>In adults with <b>CKD and an ACR under 70 mg/mmol</b>, aim for a systolic blood pressure below 140 mmHg (target range 120 to 139 mmHg) and a diastolic blood pressure below 90 mmHg</li> </ul> </li> <li><b>UK: ABCD & Renal association guidance 2021</b> <ul> <li>T2DM + CKD + ACR > 3 mg/mmol – Target BP < 130/80 mmHg</li> </ul> </li> </ul> </div>
  - Pharmacotherapy for proteinuria^{NICE CKD DRAFT 2021}
    - Offer an ACE inhibitor or an ARB <div class="navybox"> <p>For adults with CKD and diabetes (type 1 or type 2), offer:</p> <ul> <li>an ACE inhibitor or an ARB if <b>ACR is 3 mg/mmol or more</b></li> </ul> </div> and titrate to the optimal tolerated dose
      
      Check eGFR and potassium before initiation. Repeat 1 – 2 weeks after start and after each dose increase. <div class="navybox"> <p><b><u>Renin-angiotensin system antagonists</u></b></p> <ul> <li>Do not routinely offer if pretreatment potassium > 5.0 mmol/l. <ul> <li>If an adult cannot use renin–angiotensin system antagonists because of hyperkalaemia: <ul> <li>assess for and treat any other factors that promote hyperkalaemia <b>and</b></li> <li>recheck serum potassium concentration.</li> </ul> </li> </ul> </li> <li><b>STOP if potassium ≥ 6.0 mmol/l</b> and other drugs known to promote hyperkalaemia have been discontinued.</li> <li><b>If eGFR drop < 25%</b> (or creatinine < 30%) repeat test in 1-2 weeks without modifying the renin–angiotensin system antagonist dose </li> <li><b>If eGFR drop ≥ 25%</b> (or creatinine ≥ 30%) <ul> <li>investigate other causes of a deterioration in renal function, such as volume depletion or concurrent medication (for example, NSAIDs)</li> <li>if no other cause for the deterioration in renal function is found, stop the renin–angiotensin system antagonist or reduce the dose to a previously tolerated lower dose, and add an alternative antihypertensive medication if needed.</li> </ul> </li> </ul> </div>
  - Cholesterol management^{NICE CG181}
    - Offer atorvastatin 20 mg for the primary or secondary prevention of CVD to people with CKD.
    - Increase the dose if a > 40% reduction in non‑HDL cholesterol is not achieved and eGFR is ≥ 30 ml/min.
  - Hyperglycaemia Management
    - Diabetic medication adjustment in CKD
    - An update to NICE guidance for T2DM is awaited
  Alternative guidelines: 2020 KDIGO Diabetes Management in CKD Guideline
  
  Recommendations and select practice points
  
  Kidney–heart risk factor management
  
  Factors guiding decisions on individual glycated hemoglobin (HbA1c) targets
  
  Treatment algorithm for selecting antihyperglycemic drugs for patients with type 2 diabetes and chronic kidney disease
  
  Patient factors influencing the selection of glucose-lowering drugs other than sodium–glucose cotransporter-2 inhibitors and metformin in type 2 diabetes and chronic kidney disease
- CKD G1A3 – High risk – monitor <div class="navybox"> <p><b>Frequency of monitoring</b></p> <ul> <li>Agree the frequency of monitoring (eGFR and ACR) with patients (and their family members or carers, as appropriate), bearing in mind that CKD is not progressive in many people.</li> <li>The minimum frequency of eGFR monitoring is mentioned, but tailor it according to: <ul> <li>the underlying cause of CKD</li> <li>the rate of decline in eGFR or increase in ACR (but be aware that CKD progression is often non-linear)</li> <li>other risk factors, including heart failure, diabetes and hypertension</li> <li>changes to their treatment (such as renin–angiotensin–aldosterone system [RAAS] antagonists, NSAIDs and diuretics)</li> <li>intercurrent illness</li> <li>whether they have chosen conservative management of CKD.</li> </ul> </li> </ul> </div> 1 or more times a year
  - Lifestyle Advice^{NICE CKD DRAFT 2021}
    - Encourage adults with CKD to take exercise, achieve a healthy weight and stop smoking.
    - Do not offer low-protein diets (dietary protein intake < 0.6 to 0.8 g/kg/day) to adults with CKD.
  - Risk assessment^{NICE CKD DRAFT 2021}
    - Give information about patients absolute risk and their 5-year risk of needing renal replacement therapy <div class="navybox"> <ul> <li>The draft NICE guidance suggests <a href="https://www.nice.org.uk/guidance/gid-ng10118/documents/draft-guideline#page=49" target="_blank" rel="noopener">4-variable Kidney Failure Risk Equation</a></li> <li>Here is a more intuitive calculator (NOT FROM NICE GUIDANCE): <a href="https://kidneyfailurerisk.com/" target="_blank" rel="noopener">kidneyfailurerisk.com</a></li> </ul> </div>
  - BLOOD PRESSSURE CONTROL^{NICE CKD DRAFT 2021}
    - Aim for BP < 140/90 if ACR under 70 mg/mmol <div class="navybox"> <ul> <li><b>NICE DRAFT 2021</b> <ul> <li>In adults with <b>CKD and an ACR under 70 mg/mmol</b>, aim for a systolic blood pressure below 140 mmHg (target range 120 to 139 mmHg) and a diastolic blood pressure below 90 mmHg</li> </ul> </li> <li><b>UK: ABCD & Renal association guidance 2021</b> <ul> <li>T2DM + CKD + ACR > 3 mg/mmol – Target BP < 130/80 mmHg</li> </ul> </li> </ul> </div>
    - Aim for BP < 130/80 if ACR of 70 mg/mmol or more <div class="navybox">In adults with <b>CKD and an ACR of 70 mg/mmol or more</b>, aim for a systolic blood pressure below 130 mmHg (target range 120 to 129 mmHg) and a diastolic blood pressure below 80 mmHg.</div>
  - Pharmacotherapy for proteinuria^{NICE CKD DRAFT 2021}
    - Offer an ACE inhibitor or an ARB <div class="navybox"> <p>For adults with CKD and diabetes (type 1 or type 2), offer:</p> <ul> <li>an ACE inhibitor or an ARB if <b>ACR is 3 mg/mmol or more</b></li> </ul> </div> and titrate to the optimal tolerated dose
      
      Check eGFR and potassium before initiation. Repeat 1 – 2 weeks after start and after each dose increase. <div class="navybox"> <p><b><u>Renin-angiotensin system antagonists</u></b></p> <ul> <li>Do not routinely offer if pretreatment potassium > 5.0 mmol/l. <ul> <li>If an adult cannot use renin–angiotensin system antagonists because of hyperkalaemia: <ul> <li>assess for and treat any other factors that promote hyperkalaemia <b>and</b></li> <li>recheck serum potassium concentration.</li> </ul> </li> </ul> </li> <li><b>STOP if potassium ≥ 6.0 mmol/l</b> and other drugs known to promote hyperkalaemia have been discontinued.</li> <li><b>If eGFR drop < 25%</b> (or creatinine < 30%) repeat test in 1-2 weeks without modifying the renin–angiotensin system antagonist dose</li> <li><b>If eGFR drop ≥ 25%</b> (or creatinine ≥ 30%) <ul> <li>investigate other causes of a deterioration in renal function, such as volume depletion or concurrent medication (for example, NSAIDs)</li> <li>if no other cause for the deterioration in renal function is found, stop the renin–angiotensin system antagonist or reduce the dose to a previously tolerated lower dose, and add an alternative antihypertensive medication if needed.</li> </ul> </li> </ul> </div>
    - Offer an SGLT2 inhibitor <div class="navybox"> <p>For adults with CKD and type 2 diabetes, offer:</p> <ul> <li>an SGLT2 inhibitor, <u>in addition to an ACE inhibitor or an ARB</u>, if they have an ACR of 30 mg/mmol or more and meet the criteria in the marketing authorisation (including relevant eGFR thresholds); monitor for volume depletion and eGFR decline.</li> </ul> </div>
  - Cholesterol management^{NICE CG181}
    - Offer atorvastatin 20 mg for the primary or secondary prevention of CVD to people with CKD.
    - Increase the dose if a > 40% reduction in non‑HDL cholesterol is not achieved and eGFR is ≥ 30 ml/min.
  - Hyperglycaemia Management
    - Diabetic medication adjustment in CKD
    - An update to NICE guidance for T2DM is awaited
  Alternative guidelines: 2020 KDIGO Diabetes Management in CKD Guideline
  
  Recommendations and select practice points
  
  Kidney–heart risk factor management
  
  Factors guiding decisions on individual glycated hemoglobin (HbA1c) targets
  
  Treatment algorithm for selecting antihyperglycemic drugs for patients with type 2 diabetes and chronic kidney disease
  
  Patient factors influencing the selection of glucose-lowering drugs other than sodium–glucose cotransporter-2 inhibitors and metformin in type 2 diabetes and chronic kidney disease
- No CKD in the abscence of markers of kidney damage <div class="navybox"> <p><b><u>Markers of kidney disease which may be present include:</u></b></p> <ul> <li>Proteinuria</li> <li>Haematuria (of presumed or proven renal origin)</li> <li>Structural abnormalities (e.g. reflux nephropathy, renal dysgenesis, medullary sponge kidney)</li> <li>A known diagnosis of a genetic kidney disease (e.g. polycystic kidney disease)</li> <li>Abnormalities detected by examination of renal histology</li> <li>Electrolyte abnormalities due to renal tubular disorders</li> <li>History of kidney transplantation</li> </ul> </div>
- CKD G2A2 – Moderate risk – monitor <div class="navybox"> <p><b>Frequency of monitoring</b></p> <ul> <li>Agree the frequency of monitoring (eGFR and ACR) with patients (and their family members or carers, as appropriate), bearing in mind that CKD is not progressive in many people.</li> <li>The minimum frequency of eGFR monitoring is mentioned, but tailor it according to: <ul> <li>the underlying cause of CKD</li> <li>the rate of decline in eGFR or increase in ACR (but be aware that CKD progression is often non-linear)</li> <li>other risk factors, including heart failure, diabetes and hypertension</li> <li>changes to their treatment (such as renin–angiotensin–aldosterone system [RAAS] antagonists, NSAIDs and diuretics)</li> <li>intercurrent illness</li> <li>whether they have chosen conservative management of CKD.</li> </ul> </li> </ul> </div> once a year
  - Lifestyle Advice^{NICE CKD DRAFT 2021}
    - Encourage adults with CKD to take exercise, achieve a healthy weight and stop smoking.
    - Do not offer low-protein diets (dietary protein intake < 0.6 to 0.8 g/kg/day) to adults with CKD.
  - Risk assessment^{NICE CKD DRAFT 2021}
    - Give information about patients absolute risk and their 5-year risk of needing renal replacement therapy <div class="navybox"> <ul> <li>The draft NICE guidance suggests <a href="https://www.nice.org.uk/guidance/gid-ng10118/documents/draft-guideline#page=49" target="_blank">4-variable Kidney Failure Risk Equation</a></li> <li>Here is a more intuitive calculator (NOT FROM NICE GUIDANCE): <a href="https://kidneyfailurerisk.com/" target="_blank">kidneyfailurerisk.com</a></li> </ul> </div>
  - BLOOD PRESSSURE CONTROL^{NICE CKD DRAFT 2021}
    - Aim for BP < 140/90 <div class="navybox"> <ul> <li><b>NICE DRAFT 2021</b> <ul> <li>In adults with <b>CKD and an ACR under 70 mg/mmol</b>, aim for a systolic blood pressure below 140 mmHg (target range 120 to 139 mmHg) and a diastolic blood pressure below 90 mmHg</li> </ul> </li> <li><b>UK: ABCD & Renal association guidance 2021</b> <ul> <li>T2DM + CKD + ACR > 3 mg/mmol – Target BP < 130/80 mmHg</li> </ul> </li> </ul> </div>
  - Pharmacotherapy for proteinuria^{NICE CKD DRAFT 2021}
    - Offer an ACE inhibitor or an ARB <div class="navybox"> <p>For adults with CKD and diabetes (type 1 or type 2), offer:</p> <ul> <li>an ACE inhibitor or an ARB if <b>ACR is 3 mg/mmol or more</b></li> </ul> </div> and titrate to the optimal tolerated dose
      
      Check eGFR and potassium before initiation. Repeat 1 – 2 weeks after start and after each dose increase. <div class="navybox"> <p><b><u>Renin-angiotensin system antagonists</u></b></p> <ul> <li>Do not routinely offer if pretreatment potassium > 5.0 mmol/l. <ul> <li>If an adult cannot use renin–angiotensin system antagonists because of hyperkalaemia: <ul> <li>assess for and treat any other factors that promote hyperkalaemia <b>and</b></li> <li>recheck serum potassium concentration.</li> </ul> </li> </ul> </li> <li><b>STOP if potassium ≥ 6.0 mmol/l</b> and other drugs known to promote hyperkalaemia have been discontinued.</li> <li><b>If eGFR drop < 25%</b> (or creatinine < 30%) repeat test in 1-2 weeks without modifying the renin–angiotensin system antagonist dose </li> <li><b>If eGFR drop ≥ 25%</b> (or creatinine ≥ 30%) <ul> <li>investigate other causes of a deterioration in renal function, such as volume depletion or concurrent medication (for example, NSAIDs)</li> <li>if no other cause for the deterioration in renal function is found, stop the renin–angiotensin system antagonist or reduce the dose to a previously tolerated lower dose, and add an alternative antihypertensive medication if needed.</li> </ul> </li> </ul> </div>
  - Cholesterol management^{NICE CG181}
    - Offer atorvastatin 20 mg for the primary or secondary prevention of CVD to people with CKD.
    - Increase the dose if a > 40% reduction in non‑HDL cholesterol is not achieved and eGFR is ≥ 30 ml/min.
  - Hyperglycaemia Management
    - Diabetic medication adjustment in CKD
    - An update to NICE guidance for T2DM is awaited
  Alternative guidelines: 2020 KDIGO Diabetes Management in CKD Guideline
  
  Recommendations and select practice points
  
  Kidney–heart risk factor management
  
  Factors guiding decisions on individual glycated hemoglobin (HbA1c) targets
  
  Treatment algorithm for selecting antihyperglycemic drugs for patients with type 2 diabetes and chronic kidney disease
  
  Patient factors influencing the selection of glucose-lowering drugs other than sodium–glucose cotransporter-2 inhibitors and metformin in type 2 diabetes and chronic kidney disease
- CKD G2A3 – High risk – monitor <div class="navybox"> <p><b>Frequency of monitoring</b></p> <ul> <li>Agree the frequency of monitoring (eGFR and ACR) with patients (and their family members or carers, as appropriate), bearing in mind that CKD is not progressive in many people.</li> <li>The minimum frequency of eGFR monitoring is mentioned, but tailor it according to: <ul> <li>the underlying cause of CKD</li> <li>the rate of decline in eGFR or increase in ACR (but be aware that CKD progression is often non-linear)</li> <li>other risk factors, including heart failure, diabetes and hypertension</li> <li>changes to their treatment (such as renin–angiotensin–aldosterone system [RAAS] antagonists, NSAIDs and diuretics)</li> <li>intercurrent illness</li> <li>whether they have chosen conservative management of CKD.</li> </ul> </li> </ul> </div> 1 or more times a year
  - Lifestyle Advice^{NICE CKD DRAFT 2021}
    - Encourage adults with CKD to take exercise, achieve a healthy weight and stop smoking.
    - Do not offer low-protein diets (dietary protein intake < 0.6 to 0.8 g/kg/day) to adults with CKD.
  - Risk assessment^{NICE CKD DRAFT 2021}
    - Give information about patients absolute risk and their 5-year risk of needing renal replacement therapy <div class="navybox"> <ul> <li>The draft NICE guidance suggests <a href="https://www.nice.org.uk/guidance/gid-ng10118/documents/draft-guideline#page=49" target="_blank">4-variable Kidney Failure Risk Equation</a></li> <li>Here is a more intuitive calculator (NOT FROM NICE GUIDANCE): <a href="https://kidneyfailurerisk.com/" target="_blank">kidneyfailurerisk.com</a></li> </ul> </div>
  - BLOOD PRESSSURE CONTROL^{NICE CKD DRAFT 2021}
    - Aim for BP < 140/90 if ACR under 70 mg/mmol <div class="navybox"> <ul> <li><b>NICE DRAFT 2021</b> <ul> <li>In adults with <b>CKD and an ACR under 70 mg/mmol</b>, aim for a systolic blood pressure below 140 mmHg (target range 120 to 139 mmHg) and a diastolic blood pressure below 90 mmHg</li> </ul> </li> <li><b>UK: ABCD & Renal association guidance 2021</b> <ul> <li>T2DM + CKD + ACR > 3 mg/mmol – Target BP < 130/80 mmHg</li> </ul> </li> </ul> </div>
    - Aim for BP < 130/80 if ACR of 70 mg/mmol or more <div class="navybox"> In adults with <b>CKD and an ACR of 70 mg/mmol or more</b>, aim for a systolic blood pressure below 130 mmHg (target range 120 to 129 mmHg) and a diastolic blood pressure below 80 mmHg. </div>
  - Pharmacotherapy for proteinuria^{NICE CKD DRAFT 2021}
    - Offer an ACE inhibitor or an ARB <div class="navybox"> <p>For adults with CKD and diabetes (type 1 or type 2), offer:</p> <ul> <li>an ACE inhibitor or an ARB if <b>ACR is 3 mg/mmol or more</b></li> </ul> </div> and titrate to the optimal tolerated dose
      
      Check eGFR and potassium before initiation. Repeat 1 – 2 weeks after start and after each dose increase. <div class="navybox"> <p><b><u>Renin-angiotensin system antagonists</u></b></p> <ul> <li>Do not routinely offer if pretreatment potassium > 5.0 mmol/l. <ul> <li>If an adult cannot use renin–angiotensin system antagonists because of hyperkalaemia: <ul> <li>assess for and treat any other factors that promote hyperkalaemia <b>and</b></li> <li>recheck serum potassium concentration.</li> </ul> </li> </ul> </li> <li><b>STOP if potassium ≥ 6.0 mmol/l</b> and other drugs known to promote hyperkalaemia have been discontinued.</li> <li><b>If eGFR drop < 25%</b> (or creatinine < 30%) repeat test in 1-2 weeks without modifying the renin–angiotensin system antagonist dose </li> <li><b>If eGFR drop ≥ 25%</b> (or creatinine ≥ 30%) <ul> <li>investigate other causes of a deterioration in renal function, such as volume depletion or concurrent medication (for example, NSAIDs)</li> <li>if no other cause for the deterioration in renal function is found, stop the renin–angiotensin system antagonist or reduce the dose to a previously tolerated lower dose, and add an alternative antihypertensive medication if needed.</li> </ul> </li> </ul> </div>
    - Offer an SGLT2 inhibitor <div class="navybox"> <p>For adults with CKD and type 2 diabetes, offer:</p> <ul> <li>an SGLT2 inhibitor, <u>in addition to an ACE inhibitor or an ARB</u>, if they have an ACR of 30 mg/mmol or more and meet the criteria in the marketing authorisation (including relevant eGFR thresholds); monitor for volume depletion and eGFR decline.</li> </ul> </div>
  - Cholesterol management^{NICE CG181}
    - Offer atorvastatin 20 mg for the primary or secondary prevention of CVD to people with CKD.
    - Increase the dose if a > 40% reduction in non‑HDL cholesterol is not achieved and eGFR is ≥ 30 ml/min.
  - Hyperglycaemia Management
    - Diabetic medication adjustment in CKD
    - An update to NICE guidance for T2DM is awaited
  Alternative guidelines: 2020 KDIGO Diabetes Management in CKD Guideline
  
  Recommendations and select practice points
  
  Kidney–heart risk factor management
  
  Factors guiding decisions on individual glycated hemoglobin (HbA1c) targets
  
  Treatment algorithm for selecting antihyperglycemic drugs for patients with type 2 diabetes and chronic kidney disease
  
  Patient factors influencing the selection of glucose-lowering drugs other than sodium–glucose cotransporter-2 inhibitors and metformin in type 2 diabetes and chronic kidney disease
- CKD G3aA1 – Moderate risk – monitor <div class="navybox"> <p><b>Frequency of monitoring</b></p> <ul> <li>Agree the frequency of monitoring (eGFR and ACR) with patients (and their family members or carers, as appropriate), bearing in mind that CKD is not progressive in many people.</li> <li>The minimum frequency of eGFR monitoring is mentioned, but tailor it according to: <ul> <li>the underlying cause of CKD</li> <li>the rate of decline in eGFR or increase in ACR (but be aware that CKD progression is often non-linear)</li> <li>other risk factors, including heart failure, diabetes and hypertension</li> <li>changes to their treatment (such as renin–angiotensin–aldosterone system [RAAS] antagonists, NSAIDs and diuretics)</li> <li>intercurrent illness</li> <li>whether they have chosen conservative management of CKD.</li> </ul> </li> </ul> </div> once a year
  - Lifestyle Advice^{NICE CKD DRAFT 2021}
    - Encourage adults with CKD to take exercise, achieve a healthy weight and stop smoking.
    - Do not offer low-protein diets (dietary protein intake < 0.6 to 0.8 g/kg/day) to adults with CKD.
  - Risk assessment^{NICE CKD DRAFT 2021}
    - Give information about patients absolute risk and their 5-year risk of needing renal replacement therapy <div class="navybox"> <ul> <li>The draft NICE guidance suggests <a href="https://www.nice.org.uk/guidance/gid-ng10118/documents/draft-guideline#page=49" target="_blank">4-variable Kidney Failure Risk Equation</a></li> <li>Here is a more intuitive calculator (NOT FROM NICE GUIDANCE): <a href="https://kidneyfailurerisk.com/" target="_blank">kidneyfailurerisk.com</a></li> </ul> </div>
  - BLOOD PRESSSURE CONTROL^{NICE CKD DRAFT 2021}
    - Aim for BP < 140/90 <div class="navybox"> <ul> <li><b>NICE DRAFT 2021</b> <ul> <li>In adults with <b>CKD and an ACR under 70 mg/mmol</b>, aim for a systolic blood pressure below 140 mmHg (target range 120 to 139 mmHg) and a diastolic blood pressure below 90 mmHg</li> </ul> </li> </ul> </div>
  - Cholesterol management^{NICE CG181}
    - Offer atorvastatin 20 mg for the primary or secondary prevention of CVD to people with CKD.
    - Increase the dose if a > 40% reduction in non‑HDL cholesterol is not achieved and eGFR is ≥ 30 ml/min.
  - Hyperglycaemia Management
    - Diabetic medication adjustment in CKD
    - An update to NICE guidance for T2DM is awaited
  Alternative guidelines: 2020 KDIGO Diabetes Management in CKD Guideline
  
  Recommendations and select practice points
  
  Kidney–heart risk factor management
  
  Factors guiding decisions on individual glycated hemoglobin (HbA1c) targets
  
  Treatment algorithm for selecting antihyperglycemic drugs for patients with type 2 diabetes and chronic kidney disease
  
  Patient factors influencing the selection of glucose-lowering drugs other than sodium–glucose cotransporter-2 inhibitors and metformin in type 2 diabetes and chronic kidney disease
- CKD G3aA2 – High risk – monitor <div class="navybox"> <p><b>Frequency of monitoring</b></p> <ul> <li>Agree the frequency of monitoring (eGFR and ACR) with patients (and their family members or carers, as appropriate), bearing in mind that CKD is not progressive in many people.</li> <li>The minimum frequency of eGFR monitoring is mentioned, but tailor it according to: <ul> <li>the underlying cause of CKD</li> <li>the rate of decline in eGFR or increase in ACR (but be aware that CKD progression is often non-linear)</li> <li>other risk factors, including heart failure, diabetes and hypertension</li> <li>changes to their treatment (such as renin–angiotensin–aldosterone system [RAAS] antagonists, NSAIDs and diuretics)</li> <li>intercurrent illness</li> <li>whether they have chosen conservative management of CKD.</li> </ul> </li> </ul> </div> once a year
  - Lifestyle Advice^{NICE CKD DRAFT 2021}
    - Encourage adults with CKD to take exercise, achieve a healthy weight and stop smoking.
    - Do not offer low-protein diets (dietary protein intake < 0.6 to 0.8 g/kg/day) to adults with CKD.
  - Risk assessment^{NICE CKD DRAFT 2021}
    - Give information about patients absolute risk and their 5-year risk of needing renal replacement therapy <div class="navybox"> <ul> <li>The draft NICE guidance suggests <a href="https://www.nice.org.uk/guidance/gid-ng10118/documents/draft-guideline#page=49" target="_blank">4-variable Kidney Failure Risk Equation</a></li> <li>Here is a more intuitive calculator (NOT FROM NICE GUIDANCE): <a href="https://kidneyfailurerisk.com/" target="_blank">kidneyfailurerisk.com</a></li> </ul> </div>
  - BLOOD PRESSSURE CONTROL^{NICE CKD DRAFT 2021}
    - Aim for BP < 140/90 <div class="navybox"> <ul> <li><b>NICE DRAFT 2021</b> <ul> <li>In adults with <b>CKD and an ACR under 70 mg/mmol</b>, aim for a systolic blood pressure below 140 mmHg (target range 120 to 139 mmHg) and a diastolic blood pressure below 90 mmHg</li> </ul> </li> <li><b>UK: ABCD & Renal association guidance 2021</b> <ul> <li>T2DM + CKD + ACR > 3 mg/mmol – Target BP < 130/80 mmHg</li> </ul> </li> </ul> </div>
  - Pharmacotherapy for proteinuria^{NICE CKD DRAFT 2021}
    - Offer an ACE inhibitor or an ARB <div class="navybox"> <p>For adults with CKD and diabetes (type 1 or type 2), offer:</p> <ul> <li>an ACE inhibitor or an ARB if <b>ACR is 3 mg/mmol or more</b></li> </ul> </div> and titrate to the optimal tolerated dose
      
      Check eGFR and potassium before initiation. Repeat 1 – 2 weeks after start and after each dose increase. <div class="navybox"> <p><b><u>Renin-angiotensin system antagonists</u></b></p> <ul> <li>Do not routinely offer if pretreatment potassium > 5.0 mmol/l. <ul> <li>If an adult cannot use renin–angiotensin system antagonists because of hyperkalaemia: <ul> <li>assess for and treat any other factors that promote hyperkalaemia <b>and</b></li> <li>recheck serum potassium concentration.</li> </ul> </li> </ul> </li> <li><b>STOP if potassium ≥ 6.0 mmol/l</b> and other drugs known to promote hyperkalaemia have been discontinued.</li> <li><b>If eGFR drop < 25%</b> (or creatinine < 30%) repeat test in 1-2 weeks without modifying the renin–angiotensin system antagonist dose </li> <li><b>If eGFR drop ≥ 25%</b> (or creatinine ≥ 30%) <ul> <li>investigate other causes of a deterioration in renal function, such as volume depletion or concurrent medication (for example, NSAIDs)</li> <li>if no other cause for the deterioration in renal function is found, stop the renin–angiotensin system antagonist or reduce the dose to a previously tolerated lower dose, and add an alternative antihypertensive medication if needed.</li> </ul> </li> </ul> </div>
  - Cholesterol management^{NICE CG181}
    - Offer atorvastatin 20 mg for the primary or secondary prevention of CVD to people with CKD.
    - Increase the dose if a > 40% reduction in non‑HDL cholesterol is not achieved and eGFR is ≥ 30 ml/min.
  - Hyperglycaemia Management
    - Diabetic medication adjustment in CKD
    - An update to NICE guidance for T2DM is awaited
  Alternative guidelines: 2020 KDIGO Diabetes Management in CKD Guideline
  
  Recommendations and select practice points
  
  Kidney–heart risk factor management
  
  Factors guiding decisions on individual glycated hemoglobin (HbA1c) targets
  
  Treatment algorithm for selecting antihyperglycemic drugs for patients with type 2 diabetes and chronic kidney disease
  
  Patient factors influencing the selection of glucose-lowering drugs other than sodium–glucose cotransporter-2 inhibitors and metformin in type 2 diabetes and chronic kidney disease
- CKD G3aA3 – Very high risk – monitor <div class="navybox"> <p><b>Frequency of monitoring</b></p> <ul> <li>Agree the frequency of monitoring (eGFR and ACR) with patients (and their family members or carers, as appropriate), bearing in mind that CKD is not progressive in many people.</li> <li>The minimum frequency of eGFR monitoring is mentioned, but tailor it according to: <ul> <li>the underlying cause of CKD</li> <li>the rate of decline in eGFR or increase in ACR (but be aware that CKD progression is often non-linear)</li> <li>other risk factors, including heart failure, diabetes and hypertension</li> <li>changes to their treatment (such as renin–angiotensin–aldosterone system [RAAS] antagonists, NSAIDs and diuretics)</li> <li>intercurrent illness</li> <li>whether they have chosen conservative management of CKD.</li> </ul> </li> </ul> </div> 2 times a year
  - Lifestyle Advice^{NICE CKD DRAFT 2021}
    - Encourage adults with CKD to take exercise, achieve a healthy weight and stop smoking.
    - Do not offer low-protein diets (dietary protein intake < 0.6 to 0.8 g/kg/day) to adults with CKD.
  - Risk assessment^{NICE CKD DRAFT 2021}
    - Give information about patients absolute risk and their 5-year risk of needing renal replacement therapy <div class="navybox"> <ul> <li>The draft NICE guidance suggests <a href="https://www.nice.org.uk/guidance/gid-ng10118/documents/draft-guideline#page=49" target="_blank">4-variable Kidney Failure Risk Equation</a></li> <li>Here is a more intuitive calculator (NOT FROM NICE GUIDANCE): <a href="https://kidneyfailurerisk.com/" target="_blank">kidneyfailurerisk.com</a></li> </ul> </div>
  - BLOOD PRESSSURE CONTROL^{NICE CKD DRAFT 2021}
    - Aim for BP < 140/90 if ACR under 70 mg/mmol <div class="navybox"> <ul> <li><b>NICE DRAFT 2021</b> <ul> <li>In adults with <b>CKD and an ACR under 70 mg/mmol</b>, aim for a systolic blood pressure below 140 mmHg (target range 120 to 139 mmHg) and a diastolic blood pressure below 90 mmHg</li> </ul> </li> <li><b>UK: ABCD & Renal association guidance 2021</b> <ul> <li>T2DM + CKD + ACR > 3 mg/mmol – Target BP < 130/80 mmHg</li> </ul> </li> </ul> </div>
    - Aim for BP < 130/80 if ACR of 70 mg/mmol or more <div class="navybox"> In adults with <b>CKD and an ACR of 70 mg/mmol or more</b>, aim for a systolic blood pressure below 130 mmHg (target range 120 to 129 mmHg) and a diastolic blood pressure below 80 mmHg. </div>
  - Pharmacotherapy for proteinuria^{NICE CKD DRAFT 2021}
    - Offer an ACE inhibitor or an ARB <div class="navybox"> <p>For adults with CKD and diabetes (type 1 or type 2), offer:</p> <ul> <li>an ACE inhibitor or an ARB if <b>ACR is 3 mg/mmol or more</b></li> </ul> </div> and titrate to the optimal tolerated dose
      
      Check eGFR and potassium before initiation. Repeat 1 – 2 weeks after start and after each dose increase. <div class="navybox"> <p><b><u>Renin-angiotensin system antagonists</u></b></p> <ul> <li>Do not routinely offer if pretreatment potassium > 5.0 mmol/l. <ul> <li>If an adult cannot use renin–angiotensin system antagonists because of hyperkalaemia: <ul> <li>assess for and treat any other factors that promote hyperkalaemia <b>and</b></li> <li>recheck serum potassium concentration.</li> </ul> </li> </ul> </li> <li><b>STOP if potassium ≥ 6.0 mmol/l</b> and other drugs known to promote hyperkalaemia have been discontinued.</li> <li><b>If eGFR drop < 25%</b> (or creatinine < 30%) repeat test in 1-2 weeks without modifying the renin–angiotensin system antagonist dose </li> <li><b>If eGFR drop ≥ 25%</b> (or creatinine ≥ 30%) <ul> <li>investigate other causes of a deterioration in renal function, such as volume depletion or concurrent medication (for example, NSAIDs)</li> <li>if no other cause for the deterioration in renal function is found, stop the renin–angiotensin system antagonist or reduce the dose to a previously tolerated lower dose, and add an alternative antihypertensive medication if needed.</li> </ul> </li> </ul> </div>
    - Offer an SGLT2 inhibitor <div class="navybox"> <p>For adults with CKD and type 2 diabetes, offer:</p> <ul> <li>an SGLT2 inhibitor, <u>in addition to an ACE inhibitor or an ARB</u>, if they have an ACR of 30 mg/mmol or more and meet the criteria in the marketing authorisation (including relevant eGFR thresholds); monitor for volume depletion and eGFR decline.</li> </ul> </div> – only Canagliflozin 100mg licensed in UK
  - Cholesterol management^{NICE CG181}
    - Offer atorvastatin 20 mg for the primary or secondary prevention of CVD to people with CKD.
    - Increase the dose if a > 40% reduction in non‑HDL cholesterol is not achieved and eGFR is ≥ 30 ml/min.
  - Hyperglycaemia Management
    - Diabetic medication adjustment in CKD
    - An update to NICE guidance for T2DM is awaited
  Alternative guidelines: 2020 KDIGO Diabetes Management in CKD Guideline
  
  Recommendations and select practice points
  
  Kidney–heart risk factor management
  
  Factors guiding decisions on individual glycated hemoglobin (HbA1c) targets
  
  Treatment algorithm for selecting antihyperglycemic drugs for patients with type 2 diabetes and chronic kidney disease
  
  Patient factors influencing the selection of glucose-lowering drugs other than sodium–glucose cotransporter-2 inhibitors and metformin in type 2 diabetes and chronic kidney disease
- CKD G3bA1 – High risk – monitor <div class="navybox"> <p><b>Frequency of monitoring</b></p> <ul> <li>Agree the frequency of monitoring (eGFR and ACR) with patients (and their family members or carers, as appropriate), bearing in mind that CKD is not progressive in many people.</li> <li>The minimum frequency of eGFR monitoring is mentioned, but tailor it according to: <ul> <li>the underlying cause of CKD</li> <li>the rate of decline in eGFR or increase in ACR (but be aware that CKD progression is often non-linear)</li> <li>other risk factors, including heart failure, diabetes and hypertension</li> <li>changes to their treatment (such as renin–angiotensin–aldosterone system [RAAS] antagonists, NSAIDs and diuretics)</li> <li>intercurrent illness</li> <li>whether they have chosen conservative management of CKD.</li> </ul> </li> </ul> </div> 1 to 2 times a year
  - Lifestyle Advice^{NICE CKD DRAFT 2021}
    - Encourage adults with CKD to take exercise, achieve a healthy weight and stop smoking.
    - Do not offer low-protein diets (dietary protein intake < 0.6 to 0.8 g/kg/day) to adults with CKD.
  - Risk assessment^{NICE CKD DRAFT 2021}
    - Give information about patients absolute risk and their 5-year risk of needing renal replacement therapy <div class="navybox"> <ul> <li>The draft NICE guidance suggests <a href="https://www.nice.org.uk/guidance/gid-ng10118/documents/draft-guideline#page=49" target="_blank">4-variable Kidney Failure Risk Equation</a></li> <li>Here is a more intuitive calculator (NOT FROM NICE GUIDANCE): <a href="https://kidneyfailurerisk.com/" target="_blank">kidneyfailurerisk.com</a></li> </ul> </div>
  - BLOOD PRESSSURE CONTROL^{NICE CKD DRAFT 2021}
    - Aim for BP < 140/90 <div class="navybox"> <ul> <li><b>NICE DRAFT 2021</b> <ul> <li>In adults with <b>CKD and an ACR under 70 mg/mmol</b>, aim for a systolic blood pressure below 140 mmHg (target range 120 to 139 mmHg) and a diastolic blood pressure below 90 mmHg</li> </ul> </li> </ul> </div>
  - Cholesterol management^{NICE CG181}
    - Offer atorvastatin 20 mg for the primary or secondary prevention of CVD to people with CKD.
    - Increase the dose if a > 40% reduction in non‑HDL cholesterol is not achieved and eGFR is ≥ 30 ml/min.
  - Hyperglycaemia Management
    - Diabetic medication adjustment in CKD
    - An update to NICE guidance for T2DM is awaited
  Alternative guidelines: 2020 KDIGO Diabetes Management in CKD Guideline
  
  Recommendations and select practice points
  
  Kidney–heart risk factor management
  
  Factors guiding decisions on individual glycated hemoglobin (HbA1c) targets
  
  Treatment algorithm for selecting antihyperglycemic drugs for patients with type 2 diabetes and chronic kidney disease
  
  Patient factors influencing the selection of glucose-lowering drugs other than sodium–glucose cotransporter-2 inhibitors and metformin in type 2 diabetes and chronic kidney disease
- CKD G3bA2 – Very high risk – monitor <div class="navybox"> <p><b>Frequency of monitoring</b></p> <ul> <li>Agree the frequency of monitoring (eGFR and ACR) with patients (and their family members or carers, as appropriate), bearing in mind that CKD is not progressive in many people.</li> <li>The minimum frequency of eGFR monitoring is mentioned, but tailor it according to: <ul> <li>the underlying cause of CKD</li> <li>the rate of decline in eGFR or increase in ACR (but be aware that CKD progression is often non-linear)</li> <li>other risk factors, including heart failure, diabetes and hypertension</li> <li>changes to their treatment (such as renin–angiotensin–aldosterone system [RAAS] antagonists, NSAIDs and diuretics)</li> <li>intercurrent illness</li> <li>whether they have chosen conservative management of CKD.</li> </ul> </li> </ul> </div> 2 times a year
  - Lifestyle Advice^{NICE CKD DRAFT 2021}
    - Encourage adults with CKD to take exercise, achieve a healthy weight and stop smoking.
    - Do not offer low-protein diets (dietary protein intake < 0.6 to 0.8 g/kg/day) to adults with CKD.
  - Risk assessment^{NICE CKD DRAFT 2021}
    - Give information about patients absolute risk and their 5-year risk of needing renal replacement therapy <div class="navybox"> <ul> <li>The draft NICE guidance suggests <a href="https://www.nice.org.uk/guidance/gid-ng10118/documents/draft-guideline#page=49" target="_blank">4-variable Kidney Failure Risk Equation</a></li> <li>Here is a more intuitive calculator (NOT FROM NICE GUIDANCE): <a href="https://kidneyfailurerisk.com/" target="_blank">kidneyfailurerisk.com</a></li> </ul> </div>
  - BLOOD PRESSSURE CONTROL^{NICE CKD DRAFT 2021}
    - Aim for BP < 140/90 <div class="navybox"> <ul> <li><b>NICE DRAFT 2021</b> <ul> <li>In adults with <b>CKD and an ACR under 70 mg/mmol</b>, aim for a systolic blood pressure below 140 mmHg (target range 120 to 139 mmHg) and a diastolic blood pressure below 90 mmHg</li> </ul> </li> <li><b>UK: ABCD & Renal association guidance 2021</b> <ul> <li>T2DM + CKD + ACR > 3 mg/mmol – Target BP < 130/80 mmHg</li> </ul> </li> </ul> </div>
  - Pharmacotherapy for proteinuria^{NICE CKD DRAFT 2021}
    - Offer an ACE inhibitor or an ARB <div class="navybox"> <p>For adults with CKD and diabetes (type 1 or type 2), offer:</p> <ul> <li>an ACE inhibitor or an ARB if <b>ACR is 3 mg/mmol or more</b></li> </ul> </div> and titrate to the optimal tolerated dose
      
      Check eGFR and potassium before initiation. Repeat 1 – 2 weeks after start and after each dose increase. <div class="navybox"> <p><b><u>Renin-angiotensin system antagonists</u></b></p> <ul> <li>Do not routinely offer if pretreatment potassium > 5.0 mmol/l. <ul> <li>If an adult cannot use renin–angiotensin system antagonists because of hyperkalaemia: <ul> <li>assess for and treat any other factors that promote hyperkalaemia <b>and</b></li> <li>recheck serum potassium concentration.</li> </ul> </li> </ul> </li> <li><b>STOP if potassium ≥ 6.0 mmol/l</b> and other drugs known to promote hyperkalaemia have been discontinued.</li> <li><b>If eGFR drop < 25%</b> (or creatinine < 30%) repeat test in 1-2 weeks without modifying the renin–angiotensin system antagonist dose </li> <li><b>If eGFR drop ≥ 25%</b> (or creatinine ≥ 30%) <ul> <li>investigate other causes of a deterioration in renal function, such as volume depletion or concurrent medication (for example, NSAIDs)</li> <li>if no other cause for the deterioration in renal function is found, stop the renin–angiotensin system antagonist or reduce the dose to a previously tolerated lower dose, and add an alternative antihypertensive medication if needed.</li> </ul> </li> </ul> </div>
  - Cholesterol management^{NICE CG181}
    - Offer atorvastatin 20 mg for the primary or secondary prevention of CVD to people with CKD.
    - Increase the dose if a > 40% reduction in non‑HDL cholesterol is not achieved and eGFR is ≥ 30 ml/min.
  - Hyperglycaemia Management
    - Diabetic medication adjustment in CKD
    - An update to NICE guidance for T2DM is awaited
  Alternative guidelines: 2020 KDIGO Diabetes Management in CKD Guideline
  
  Recommendations and select practice points
  
  Kidney–heart risk factor management
  
  Factors guiding decisions on individual glycated hemoglobin (HbA1c) targets
  
  Treatment algorithm for selecting antihyperglycemic drugs for patients with type 2 diabetes and chronic kidney disease
  
  Patient factors influencing the selection of glucose-lowering drugs other than sodium–glucose cotransporter-2 inhibitors and metformin in type 2 diabetes and chronic kidney disease
- CKD G3bA3 – Very high risk – monitor <div class="navybox"> <p><b>Frequency of monitoring</b></p> <ul> <li>Agree the frequency of monitoring (eGFR and ACR) with patients (and their family members or carers, as appropriate), bearing in mind that CKD is not progressive in many people.</li> <li>The minimum frequency of eGFR monitoring is mentioned, but tailor it according to: <ul> <li>the underlying cause of CKD</li> <li>the rate of decline in eGFR or increase in ACR (but be aware that CKD progression is often non-linear)</li> <li>other risk factors, including heart failure, diabetes and hypertension</li> <li>changes to their treatment (such as renin–angiotensin–aldosterone system [RAAS] antagonists, NSAIDs and diuretics)</li> <li>intercurrent illness</li> <li>whether they have chosen conservative management of CKD.</li> </ul> </li> </ul> </div> 2 or more times a year
  - Lifestyle Advice^{NICE CKD DRAFT 2021}
    - Encourage adults with CKD to take exercise, achieve a healthy weight and stop smoking.
    - Do not offer low-protein diets (dietary protein intake < 0.6 to 0.8 g/kg/day) to adults with CKD.
  - Risk assessment^{NICE CKD DRAFT 2021}
    - Give information about patients absolute risk and their 5-year risk of needing renal replacement therapy <div class="navybox"> <ul> <li>The draft NICE guidance suggests <a href="https://www.nice.org.uk/guidance/gid-ng10118/documents/draft-guideline#page=49" target="_blank">4-variable Kidney Failure Risk Equation</a></li> <li>Here is a more intuitive calculator (NOT FROM NICE GUIDANCE): <a href="https://kidneyfailurerisk.com/" target="_blank">kidneyfailurerisk.com</a></li> </ul> </div>
  - BLOOD PRESSSURE CONTROL^{NICE CKD DRAFT 2021}
    - Aim for BP < 140/90 if ACR under 70 mg/mmol <div class="navybox"> <ul> <li><b>NICE DRAFT 2021</b> <ul> <li>In adults with <b>CKD and an ACR under 70 mg/mmol</b>, aim for a systolic blood pressure below 140 mmHg (target range 120 to 139 mmHg) and a diastolic blood pressure below 90 mmHg</li> </ul> </li> <li><b>UK: ABCD & Renal association guidance 2021</b> <ul> <li>T2DM + CKD + ACR > 3 mg/mmol – Target BP < 130/80 mmHg</li> </ul> </li> </ul> </div>
    - Aim for BP < 130/80 if ACR of 70 mg/mmol or more <div class="navybox"> In adults with <b>CKD and an ACR of 70 mg/mmol or more</b>, aim for a systolic blood pressure below 130 mmHg (target range 120 to 129 mmHg) and a diastolic blood pressure below 80 mmHg. </div>
  - Pharmacotherapy for proteinuria^{NICE CKD DRAFT 2021}
    - Offer an ACE inhibitor or an ARB <div class="navybox"> <p>For adults with CKD and diabetes (type 1 or type 2), offer:</p> <ul> <li>an ACE inhibitor or an ARB if <b>ACR is 3 mg/mmol or more</b></li> </ul> </div> and titrate to the optimal tolerated dose
      
      Check eGFR and potassium before initiation. Repeat 1 – 2 weeks after start and after each dose increase. <div class="navybox"> <p><b><u>Renin-angiotensin system antagonists</u></b></p> <ul> <li>Do not routinely offer if pretreatment potassium > 5.0 mmol/l. <ul> <li>If an adult cannot use renin–angiotensin system antagonists because of hyperkalaemia: <ul> <li>assess for and treat any other factors that promote hyperkalaemia <b>and</b></li> <li>recheck serum potassium concentration.</li> </ul> </li> </ul> </li> <li><b>STOP if potassium ≥ 6.0 mmol/l</b> and other drugs known to promote hyperkalaemia have been discontinued.</li> <li><b>If eGFR drop < 25%</b> (or creatinine < 30%) repeat test in 1-2 weeks without modifying the renin–angiotensin system antagonist dose </li> <li><b>If eGFR drop ≥ 25%</b> (or creatinine ≥ 30%) <ul> <li>investigate other causes of a deterioration in renal function, such as volume depletion or concurrent medication (for example, NSAIDs)</li> <li>if no other cause for the deterioration in renal function is found, stop the renin–angiotensin system antagonist or reduce the dose to a previously tolerated lower dose, and add an alternative antihypertensive medication if needed.</li> </ul> </li> </ul> </div>
    - Offer an SGLT2 inhibitor <div class="navybox"> <p>For adults with CKD and type 2 diabetes, offer:</p> <ul> <li>an SGLT2 inhibitor, <u>in addition to an ACE inhibitor or an ARB</u>, if they have an ACR of 30 mg/mmol or more and meet the criteria in the marketing authorisation (including relevant eGFR thresholds); monitor for volume depletion and eGFR decline.</li> </ul> </div> – only Canagliflozin 100mg licensed in UK
  - Cholesterol management^{NICE CG181}
    - Offer atorvastatin 20 mg for the primary or secondary prevention of CVD to people with CKD.
    - Increase the dose if a > 40% reduction in non‑HDL cholesterol is not achieved and eGFR is ≥ 30 ml/min.
  - Hyperglycaemia Management
    - Diabetic medication adjustment in CKD
    - An update to NICE guidance for T2DM is awaited
  Alternative guidelines: 2020 KDIGO Diabetes Management in CKD Guideline
  
  Recommendations and select practice points
  
  Kidney–heart risk factor management
  
  Factors guiding decisions on individual glycated hemoglobin (HbA1c) targets
  
  Treatment algorithm for selecting antihyperglycemic drugs for patients with type 2 diabetes and chronic kidney disease
  
  Patient factors influencing the selection of glucose-lowering drugs other than sodium–glucose cotransporter-2 inhibitors and metformin in type 2 diabetes and chronic kidney disease
- CKD G4A1 – Very high risk – monitor <div class="navybox"> <p><b>Frequency of monitoring</b></p> <ul> <li>Agree the frequency of monitoring (eGFR and ACR) with patients (and their family members or carers, as appropriate), bearing in mind that CKD is not progressive in many people.</li> <li>The minimum frequency of eGFR monitoring is mentioned, but tailor it according to: <ul> <li>the underlying cause of CKD</li> <li>the rate of decline in eGFR or increase in ACR (but be aware that CKD progression is often non-linear)</li> <li>other risk factors, including heart failure, diabetes and hypertension</li> <li>changes to their treatment (such as renin–angiotensin–aldosterone system [RAAS] antagonists, NSAIDs and diuretics)</li> <li>intercurrent illness</li> <li>whether they have chosen conservative management of CKD.</li> </ul> </li> </ul> </div> 2 times a year
  - Lifestyle Advice^{NICE CKD DRAFT 2021}
    - Encourage adults with CKD to take exercise, achieve a healthy weight and stop smoking.
    - Do not offer low-protein diets (dietary protein intake < 0.6 to 0.8 g/kg/day) to adults with CKD.
  - Risk assessment^{NICE CKD DRAFT 2021}
    - Give information about patients absolute risk and their 5-year risk of needing renal replacement therapy <div class="navybox"> <ul> <li>The draft NICE guidance suggests <a href="https://www.nice.org.uk/guidance/gid-ng10118/documents/draft-guideline#page=49" target="_blank">4-variable Kidney Failure Risk Equation</a></li> <li>Here is a more intuitive calculator (NOT FROM NICE GUIDANCE): <a href="https://kidneyfailurerisk.com/" target="_blank">kidneyfailurerisk.com</a></li> </ul> </div>
  - BLOOD PRESSSURE CONTROL^{NICE CKD DRAFT 2021}
    - Aim for BP < 140/90 <div class="navybox"> <ul> <li><b>NICE DRAFT 2021</b> <ul> <li>In adults with <b>CKD and an ACR under 70 mg/mmol</b>, aim for a systolic blood pressure below 140 mmHg (target range 120 to 139 mmHg) and a diastolic blood pressure below 90 mmHg</li> </ul> </li> </ul> </div>
  - Cholesterol management^{NICE CG181}
    - Offer atorvastatin 20 mg for the primary or secondary prevention of CVD to people with CKD.
    - Agree the use of higher doses with a renal specialist if eGFR is < 30 ml/min.
  - Hyperglycaemia Management
    - Diabetic medication adjustment in CKD
    - An update to NICE guidance for T2DM is awaited
  Alternative guidelines: 2020 KDIGO Diabetes Management in CKD Guideline
  
  Recommendations and select practice points
  
  Kidney–heart risk factor management
  
  Factors guiding decisions on individual glycated hemoglobin (HbA1c) targets
  
  Treatment algorithm for selecting antihyperglycemic drugs for patients with type 2 diabetes and chronic kidney disease
  
  Patient factors influencing the selection of glucose-lowering drugs other than sodium–glucose cotransporter-2 inhibitors and metformin in type 2 diabetes and chronic kidney disease
- CKD G4A2 – Very high risk – monitor <div class="navybox"> <p><b>Frequency of monitoring</b></p> <ul> <li>Agree the frequency of monitoring (eGFR and ACR) with patients (and their family members or carers, as appropriate), bearing in mind that CKD is not progressive in many people.</li> <li>The minimum frequency of eGFR monitoring is mentioned, but tailor it according to: <ul> <li>the underlying cause of CKD</li> <li>the rate of decline in eGFR or increase in ACR (but be aware that CKD progression is often non-linear)</li> <li>other risk factors, including heart failure, diabetes and hypertension</li> <li>changes to their treatment (such as renin–angiotensin–aldosterone system [RAAS] antagonists, NSAIDs and diuretics)</li> <li>intercurrent illness</li> <li>whether they have chosen conservative management of CKD.</li> </ul> </li> </ul> </div> 2 times a year
  - Lifestyle Advice^{NICE CKD DRAFT 2021}
    - Encourage adults with CKD to take exercise, achieve a healthy weight and stop smoking.
    - Do not offer low-protein diets (dietary protein intake < 0.6 to 0.8 g/kg/day) to adults with CKD.
  - Risk assessment^{NICE CKD DRAFT 2021}
    - Give information about patients absolute risk and their 5-year risk of needing renal replacement therapy <div class="navybox"> <ul> <li>The draft NICE guidance suggests <a href="https://www.nice.org.uk/guidance/gid-ng10118/documents/draft-guideline#page=49" target="_blank">4-variable Kidney Failure Risk Equation</a></li> <li>Here is a more intuitive calculator (NOT FROM NICE GUIDANCE): <a href="https://kidneyfailurerisk.com/" target="_blank">kidneyfailurerisk.com</a></li> </ul> </div>
  - BLOOD PRESSSURE CONTROL^{NICE CKD DRAFT 2021}
    - Aim for BP < 140/90 <div class="navybox"> <ul> <li><b>NICE DRAFT 2021</b> <ul> <li>In adults with <b>CKD and an ACR under 70 mg/mmol</b>, aim for a systolic blood pressure below 140 mmHg (target range 120 to 139 mmHg) and a diastolic blood pressure below 90 mmHg</li> </ul> </li> <li><b>UK: ABCD & Renal association guidance 2021</b> <ul> <li>T2DM + CKD + ACR > 3 mg/mmol – Target BP < 130/80 mmHg</li> </ul> </li> </ul> </div>
  - Pharmacotherapy for proteinuria^{NICE CKD DRAFT 2021}
    - Offer an ACE inhibitor or an ARB <div class="navybox"> <p>For adults with CKD and diabetes (type 1 or type 2), offer:</p> <ul> <li>an ACE inhibitor or an ARB if <b>ACR is 3 mg/mmol or more</b></li> </ul> </div> and titrate to the optimal tolerated dose
      
      Check eGFR and potassium before initiation. Repeat 1 – 2 weeks after start and after each dose increase. <div class="navybox"> <p><b><u>Renin-angiotensin system antagonists</u></b></p> <ul> <li>Do not routinely offer if pretreatment potassium > 5.0 mmol/l. <ul> <li>If an adult cannot use renin–angiotensin system antagonists because of hyperkalaemia: <ul> <li>assess for and treat any other factors that promote hyperkalaemia <b>and</b></li> <li>recheck serum potassium concentration.</li> </ul> </li> </ul> </li> <li><b>STOP if potassium ≥ 6.0 mmol/l</b> and other drugs known to promote hyperkalaemia have been discontinued.</li> <li><b>If eGFR drop < 25%</b> (or creatinine < 30%) repeat test in 1-2 weeks without modifying the renin–angiotensin system antagonist dose </li> <li><b>If eGFR drop ≥ 25%</b> (or creatinine ≥ 30%) <ul> <li>investigate other causes of a deterioration in renal function, such as volume depletion or concurrent medication (for example, NSAIDs)</li> <li>if no other cause for the deterioration in renal function is found, stop the renin–angiotensin system antagonist or reduce the dose to a previously tolerated lower dose, and add an alternative antihypertensive medication if needed.</li> </ul> </li> </ul> </div>
  - Cholesterol management^{NICE CG181}
    - Offer atorvastatin 20 mg for the primary or secondary prevention of CVD to people with CKD.
    - Agree the use of higher doses with a renal specialist if eGFR is < 30 ml/min.
  - Hyperglycaemia Management
    - Diabetic medication adjustment in CKD
    - An update to NICE guidance for T2DM is awaited
  Alternative guidelines: 2020 KDIGO Diabetes Management in CKD Guideline
  
  Recommendations and select practice points
  
  Kidney–heart risk factor management
  
  Factors guiding decisions on individual glycated hemoglobin (HbA1c) targets
  
  Treatment algorithm for selecting antihyperglycemic drugs for patients with type 2 diabetes and chronic kidney disease
  
  Patient factors influencing the selection of glucose-lowering drugs other than sodium–glucose cotransporter-2 inhibitors and metformin in type 2 diabetes and chronic kidney disease
- CKD G4A3 – Very high risk – monitor <div class="navybox"> <p><b>Frequency of monitoring</b></p> <ul> <li>Agree the frequency of monitoring (eGFR and ACR) with patients (and their family members or carers, as appropriate), bearing in mind that CKD is not progressive in many people.</li> <li>The minimum frequency of eGFR monitoring is mentioned, but tailor it according to: <ul> <li>the underlying cause of CKD</li> <li>the rate of decline in eGFR or increase in ACR (but be aware that CKD progression is often non-linear)</li> <li>other risk factors, including heart failure, diabetes and hypertension</li> <li>changes to their treatment (such as renin–angiotensin–aldosterone system [RAAS] antagonists, NSAIDs and diuretics)</li> <li>intercurrent illness</li> <li>whether they have chosen conservative management of CKD.</li> </ul> </li> </ul> </div> 3 times a year
  - Lifestyle Advice^{NICE CKD DRAFT 2021}
    - Encourage adults with CKD to take exercise, achieve a healthy weight and stop smoking.
    - Do not offer low-protein diets (dietary protein intake < 0.6 to 0.8 g/kg/day) to adults with CKD.
  - Risk assessment^{NICE CKD DRAFT 2021}
    - Give information about patients absolute risk and their 5-year risk of needing renal replacement therapy <div class="navybox"> <ul> <li>The draft NICE guidance suggests <a href="https://www.nice.org.uk/guidance/gid-ng10118/documents/draft-guideline#page=49" target="_blank">4-variable Kidney Failure Risk Equation</a></li> <li>Here is a more intuitive calculator (NOT FROM NICE GUIDANCE): <a href="https://kidneyfailurerisk.com/" target="_blank">kidneyfailurerisk.com</a></li> </ul> </div>
  - BLOOD PRESSSURE CONTROL^{NICE CKD DRAFT 2021}
    - Aim for BP < 140/90 if ACR under 70 mg/mmol <div class="navybox"> <ul> <li><b>NICE DRAFT 2021</b> <ul> <li>In adults with <b>CKD and an ACR under 70 mg/mmol</b>, aim for a systolic blood pressure below 140 mmHg (target range 120 to 139 mmHg) and a diastolic blood pressure below 90 mmHg</li> </ul> </li> <li><b>UK: ABCD & Renal association guidance 2021</b> <ul> <li>T2DM + CKD + ACR > 3 mg/mmol – Target BP < 130/80 mmHg</li> </ul> </li> </ul> </div>
    - Aim for BP < 130/80 if ACR of 70 mg/mmol or more <div class="navybox"> In adults with <b>CKD and an ACR of 70 mg/mmol or more</b>, aim for a systolic blood pressure below 130 mmHg (target range 120 to 129 mmHg) and a diastolic blood pressure below 80 mmHg. </div>
  - Pharmacotherapy for proteinuria^{NICE CKD DRAFT 2021}
    - Offer an ACE inhibitor or an ARB <div class="navybox"> <p>For adults with CKD and diabetes (type 1 or type 2), offer:</p> <ul> <li>an ACE inhibitor or an ARB if <b>ACR is 3 mg/mmol or more</b></li> </ul> </div> and titrate to the optimal tolerated dose
      
      Check eGFR and potassium before initiation. Repeat 1 – 2 weeks after start and after each dose increase. <div class="navybox"> <p><b><u>Renin-angiotensin system antagonists</u></b></p> <ul> <li>Do not routinely offer if pretreatment potassium > 5.0 mmol/l. <ul> <li>If an adult cannot use renin–angiotensin system antagonists because of hyperkalaemia: <ul> <li>assess for and treat any other factors that promote hyperkalaemia <b>and</b></li> <li>recheck serum potassium concentration.</li> </ul> </li> </ul> </li> <li><b>STOP if potassium ≥ 6.0 mmol/l</b> and other drugs known to promote hyperkalaemia have been discontinued.</li> <li><b>If eGFR drop < 25%</b> (or creatinine < 30%) repeat test in 1-2 weeks without modifying the renin–angiotensin system antagonist dose </li> <li><b>If eGFR drop ≥ 25%</b> (or creatinine ≥ 30%) <ul> <li>investigate other causes of a deterioration in renal function, such as volume depletion or concurrent medication (for example, NSAIDs)</li> <li>if no other cause for the deterioration in renal function is found, stop the renin–angiotensin system antagonist or reduce the dose to a previously tolerated lower dose, and add an alternative antihypertensive medication if needed.</li> </ul> </li> </ul> </div>
    - DO NOT offer an SGLT2 inhibitor <div class="navybox"> <p>For adults with CKD and type 2 diabetes, offer:</p> <ul> <li>an SGLT2 inhibitor, <u>in addition to an ACE inhibitor or an ARB</u>, if they have an ACR of 30 mg/mmol or more and meet the criteria in the marketing authorisation (including relevant eGFR thresholds); monitor for volume depletion and eGFR decline.</li> </ul> </div> – can continue Canagliflozin 100mg if already taking but do not initiate
  - Cholesterol management^{NICE CG181}
    - Offer atorvastatin 20 mg for the primary or secondary prevention of CVD to people with CKD.
    - Agree the use of higher doses with a renal specialist if eGFR is < 30 ml/min.
  - Hyperglycaemia Management
    - Diabetic medication adjustment in CKD
    - An update to NICE guidance for T2DM is awaited
  Alternative guidelines: 2020 KDIGO Diabetes Management in CKD Guideline
  
  Recommendations and select practice points
  
  Kidney–heart risk factor management
  
  Factors guiding decisions on individual glycated hemoglobin (HbA1c) targets
  
  Treatment algorithm for selecting antihyperglycemic drugs for patients with type 2 diabetes and chronic kidney disease
  
  Patient factors influencing the selection of glucose-lowering drugs other than sodium–glucose cotransporter-2 inhibitors and metformin in type 2 diabetes and chronic kidney disease
- CKD G5A1 – Very high risk – monitor <div class="navybox"> <p><b>Frequency of monitoring</b></p> <ul> <li>Agree the frequency of monitoring (eGFR and ACR) with patients (and their family members or carers, as appropriate), bearing in mind that CKD is not progressive in many people.</li> <li>The minimum frequency of eGFR monitoring is mentioned, but tailor it according to: <ul> <li>the underlying cause of CKD</li> <li>the rate of decline in eGFR or increase in ACR (but be aware that CKD progression is often non-linear)</li> <li>other risk factors, including heart failure, diabetes and hypertension</li> <li>changes to their treatment (such as renin–angiotensin–aldosterone system [RAAS] antagonists, NSAIDs and diuretics)</li> <li>intercurrent illness</li> <li>whether they have chosen conservative management of CKD.</li> </ul> </li> </ul> </div> 4 times a year
  - Lifestyle Advice^{NICE CKD DRAFT 2021}
    - Encourage adults with CKD to take exercise, achieve a healthy weight and stop smoking.
    - Do not offer low-protein diets (dietary protein intake < 0.6 to 0.8 g/kg/day) to adults with CKD.
  - Risk assessment^{NICE CKD DRAFT 2021}
    - Give information about patients absolute risk and their 5-year risk of needing renal replacement therapy <div class="navybox"> <ul> <li>The draft NICE guidance suggests <a href="https://www.nice.org.uk/guidance/gid-ng10118/documents/draft-guideline#page=49" target="_blank">4-variable Kidney Failure Risk Equation</a></li> <li>Here is a more intuitive calculator (NOT FROM NICE GUIDANCE): <a href="https://kidneyfailurerisk.com/" target="_blank">kidneyfailurerisk.com</a></li> </ul> </div>
  - BLOOD PRESSSURE CONTROL^{NICE CKD DRAFT 2021}
    - Aim for BP < 140/90 <div class="navybox"> <ul> <li><b>NICE DRAFT 2021</b> <ul> <li>In adults with <b>CKD and an ACR under 70 mg/mmol</b>, aim for a systolic blood pressure below 140 mmHg (target range 120 to 139 mmHg) and a diastolic blood pressure below 90 mmHg</li> </ul> </li> </ul> </div>
  - Cholesterol management^{NICE CG181}
    - Offer atorvastatin 20 mg for the primary or secondary prevention of CVD to people with CKD.
    - Agree the use of higher doses with a renal specialist if eGFR is < 30 ml/min.
  - Hyperglycaemia Management
    - Diabetic medication adjustment in CKD
    - An update to NICE guidance for T2DM is awaited
  Alternative guidelines: 2020 KDIGO Diabetes Management in CKD Guideline
  
  Recommendations and select practice points
  
  Kidney–heart risk factor management
  
  Factors guiding decisions on individual glycated hemoglobin (HbA1c) targets
  
  Treatment algorithm for selecting antihyperglycemic drugs for patients with type 2 diabetes and chronic kidney disease
  
  Patient factors influencing the selection of glucose-lowering drugs other than sodium–glucose cotransporter-2 inhibitors and metformin in type 2 diabetes and chronic kidney disease
- CKD G5A2 – Very high risk – monitor <div class="navybox"> <p><b>Frequency of monitoring</b></p> <ul> <li>Agree the frequency of monitoring (eGFR and ACR) with patients (and their family members or carers, as appropriate), bearing in mind that CKD is not progressive in many people.</li> <li>The minimum frequency of eGFR monitoring is mentioned, but tailor it according to: <ul> <li>the underlying cause of CKD</li> <li>the rate of decline in eGFR or increase in ACR (but be aware that CKD progression is often non-linear)</li> <li>other risk factors, including heart failure, diabetes and hypertension</li> <li>changes to their treatment (such as renin–angiotensin–aldosterone system [RAAS] antagonists, NSAIDs and diuretics)</li> <li>intercurrent illness</li> <li>whether they have chosen conservative management of CKD.</li> </ul> </li> </ul> </div> 4 or more times a year
  - Lifestyle Advice^{NICE CKD DRAFT 2021}
    - Encourage adults with CKD to take exercise, achieve a healthy weight and stop smoking.
    - Do not offer low-protein diets (dietary protein intake < 0.6 to 0.8 g/kg/day) to adults with CKD.
  - Risk assessment^{NICE CKD DRAFT 2021}
    - Give information about patients absolute risk and their 5-year risk of needing renal replacement therapy <div class="navybox"> <ul> <li>The draft NICE guidance suggests <a href="https://www.nice.org.uk/guidance/gid-ng10118/documents/draft-guideline#page=49" target="_blank">4-variable Kidney Failure Risk Equation</a></li> <li>Here is a more intuitive calculator (NOT FROM NICE GUIDANCE): <a href="https://kidneyfailurerisk.com/" target="_blank">kidneyfailurerisk.com</a></li> </ul> </div>
  - BLOOD PRESSSURE CONTROL^{NICE CKD DRAFT 2021}
    - Aim for BP < 140/90 <div class="navybox"> <ul> <li><b>NICE DRAFT 2021</b> <ul> <li>In adults with <b>CKD and an ACR under 70 mg/mmol</b>, aim for a systolic blood pressure below 140 mmHg (target range 120 to 139 mmHg) and a diastolic blood pressure below 90 mmHg</li> </ul> </li> <li><b>UK: ABCD & Renal association guidance 2021</b> <ul> <li>T2DM + CKD + ACR > 3 mg/mmol – Target BP < 130/80 mmHg</li> </ul> </li> </ul> </div>
  - Pharmacotherapy for proteinuria^{NICE CKD DRAFT 2021}
    - Offer an ACE inhibitor or an ARB <div class="navybox"> <p>For adults with CKD and diabetes (type 1 or type 2), offer:</p> <ul> <li>an ACE inhibitor or an ARB if <b>ACR is 3 mg/mmol or more</b></li> </ul> </div> and titrate to the optimal tolerated dose
      
      Check eGFR and potassium before initiation. Repeat 1 – 2 weeks after start and after each dose increase. <div class="navybox"> <p><b><u>Renin-angiotensin system antagonists</u></b></p> <ul> <li>Do not routinely offer if pretreatment potassium > 5.0 mmol/l. <ul> <li>If an adult cannot use renin–angiotensin system antagonists because of hyperkalaemia: <ul> <li>assess for and treat any other factors that promote hyperkalaemia <b>and</b></li> <li>recheck serum potassium concentration.</li> </ul> </li> </ul> </li> <li><b>STOP if potassium ≥ 6.0 mmol/l</b> and other drugs known to promote hyperkalaemia have been discontinued.</li> <li><b>If eGFR drop < 25%</b> (or creatinine < 30%) repeat test in 1-2 weeks without modifying the renin–angiotensin system antagonist dose </li> <li><b>If eGFR drop ≥ 25%</b> (or creatinine ≥ 30%) <ul> <li>investigate other causes of a deterioration in renal function, such as volume depletion or concurrent medication (for example, NSAIDs)</li> <li>if no other cause for the deterioration in renal function is found, stop the renin–angiotensin system antagonist or reduce the dose to a previously tolerated lower dose, and add an alternative antihypertensive medication if needed.</li> </ul> </li> </ul> </div>
  - Cholesterol management^{NICE CG181}
    - Offer atorvastatin 20 mg for the primary or secondary prevention of CVD to people with CKD.
    - Agree the use of higher doses with a renal specialist if eGFR is < 30 ml/min.
  - Hyperglycaemia Management
    - Diabetic medication adjustment in CKD
    - An update to NICE guidance for T2DM is awaited
  Alternative guidelines: 2020 KDIGO Diabetes Management in CKD Guideline
  
  Recommendations and select practice points
  
  Kidney–heart risk factor management
  
  Factors guiding decisions on individual glycated hemoglobin (HbA1c) targets
  
  Treatment algorithm for selecting antihyperglycemic drugs for patients with type 2 diabetes and chronic kidney disease
  
  Patient factors influencing the selection of glucose-lowering drugs other than sodium–glucose cotransporter-2 inhibitors and metformin in type 2 diabetes and chronic kidney disease
- CKD G5A3 – Very high risk – monitor <div class="navybox"> <p><b>Frequency of monitoring</b></p> <ul> <li>Agree the frequency of monitoring (eGFR and ACR) with patients (and their family members or carers, as appropriate), bearing in mind that CKD is not progressive in many people.</li> <li>The minimum frequency of eGFR monitoring is mentioned, but tailor it according to: <ul> <li>the underlying cause of CKD</li> <li>the rate of decline in eGFR or increase in ACR (but be aware that CKD progression is often non-linear)</li> <li>other risk factors, including heart failure, diabetes and hypertension</li> <li>changes to their treatment (such as renin–angiotensin–aldosterone system [RAAS] antagonists, NSAIDs and diuretics)</li> <li>intercurrent illness</li> <li>whether they have chosen conservative management of CKD.</li> </ul> </li> </ul> </div> 4 or more times a year
  - Lifestyle Advice^{NICE CKD DRAFT 2021}
    - Encourage adults with CKD to take exercise, achieve a healthy weight and stop smoking.
    - Do not offer low-protein diets (dietary protein intake < 0.6 to 0.8 g/kg/day) to adults with CKD.
  - Risk assessment^{NICE CKD DRAFT 2021}
    - Give information about patients absolute risk and their 5-year risk of needing renal replacement therapy <div class="navybox"> <ul> <li>The draft NICE guidance suggests <a href="https://www.nice.org.uk/guidance/gid-ng10118/documents/draft-guideline#page=49" target="_blank">4-variable Kidney Failure Risk Equation</a></li> <li>Here is a more intuitive calculator (NOT FROM NICE GUIDANCE): <a href="https://kidneyfailurerisk.com/" target="_blank">kidneyfailurerisk.com</a></li> </ul> </div>
  - BLOOD PRESSSURE CONTROL^{NICE CKD DRAFT 2021}
    - Aim for BP < 140/90 if ACR under 70 mg/mmol <div class="navybox"> <ul> <li><b>NICE DRAFT 2021</b> <ul> <li>In adults with <b>CKD and an ACR under 70 mg/mmol</b>, aim for a systolic blood pressure below 140 mmHg (target range 120 to 139 mmHg) and a diastolic blood pressure below 90 mmHg</li> </ul> </li> <li><b>UK: ABCD & Renal association guidance 2021</b> <ul> <li>T2DM + CKD + ACR > 3 mg/mmol – Target BP < 130/80 mmHg</li> </ul> </li> </ul> </div>
    - Aim for BP < 130/80 if ACR of 70 mg/mmol or more <div class="navybox"> In adults with <b>CKD and an ACR of 70 mg/mmol or more</b>, aim for a systolic blood pressure below 130 mmHg (target range 120 to 129 mmHg) and a diastolic blood pressure below 80 mmHg. </div>
  - Pharmacotherapy for proteinuria^{NICE CKD DRAFT 2021}
    - Offer an ACE inhibitor or an ARB <div class="navybox"> <p>For adults with CKD and diabetes (type 1 or type 2), offer:</p> <ul> <li>an ACE inhibitor or an ARB if <b>ACR is 3 mg/mmol or more</b></li> </ul> </div> and titrate to the optimal tolerated dose
      
      Check eGFR and potassium before initiation. Repeat 1 – 2 weeks after start and after each dose increase. <div class="navybox"> <p><b><u>Renin-angiotensin system antagonists</u></b></p> <ul> <li>Do not routinely offer if pretreatment potassium > 5.0 mmol/l. <ul> <li>If an adult cannot use renin–angiotensin system antagonists because of hyperkalaemia: <ul> <li>assess for and treat any other factors that promote hyperkalaemia <b>and</b></li> <li>recheck serum potassium concentration.</li> </ul> </li> </ul> </li> <li><b>STOP if potassium ≥ 6.0 mmol/l</b> and other drugs known to promote hyperkalaemia have been discontinued.</li> <li><b>If eGFR drop < 25%</b> (or creatinine < 30%) repeat test in 1-2 weeks without modifying the renin–angiotensin system antagonist dose </li> <li><b>If eGFR drop ≥ 25%</b> (or creatinine ≥ 30%) <ul> <li>investigate other causes of a deterioration in renal function, such as volume depletion or concurrent medication (for example, NSAIDs)</li> <li>if no other cause for the deterioration in renal function is found, stop the renin–angiotensin system antagonist or reduce the dose to a previously tolerated lower dose, and add an alternative antihypertensive medication if needed.</li> </ul> </li> </ul> </div>
    - DO NOT offer an SGLT2 inhibitor <div class="navybox"> <p>For adults with CKD and type 2 diabetes, offer:</p> <ul> <li>an SGLT2 inhibitor, <u>in addition to an ACE inhibitor or an ARB</u>, if they have an ACR of 30 mg/mmol or more and meet the criteria in the marketing authorisation (including relevant eGFR thresholds); monitor for volume depletion and eGFR decline.</li> </ul> </div> – can continue Canagliflozin 100mg if already taking but do not initiate. Stop if renal replacement therapy.
  - Cholesterol management^{NICE CG181}
    - Offer atorvastatin 20 mg for the primary or secondary prevention of CVD to people with CKD.
    - Agree the use of higher doses with a renal specialist if eGFR is < 30 ml/min.
  - Hyperglycaemia Management
    - Diabetic medication adjustment in CKD
    - An update to NICE guidance for T2DM is awaited
  Alternative guidelines: 2020 KDIGO Diabetes Management in CKD Guideline
  
  Recommendations and select practice points
  
  Kidney–heart risk factor management
  
  Factors guiding decisions on individual glycated hemoglobin (HbA1c) targets
  
  Treatment algorithm for selecting antihyperglycemic drugs for patients with type 2 diabetes and chronic kidney disease
  
  Patient factors influencing the selection of glucose-lowering drugs other than sodium–glucose cotransporter-2 inhibitors and metformin in type 2 diabetes and chronic kidney disease
- Defining CKD progression in adults
  
  Define accelerated progression of CKD in adults as:
  
  a sustained decrease in GFR of 25% or more and a change in GFR category within 12 months or
  
  a sustained decrease in GFR of 15 ml/min per year.
  
  Take the following steps to identify the rate of progression of CKD:
  
  Obtain a minimum of 3 GFR estimations over a period of not less than 90 days.
  
  In adults with a new finding of reduced GFR, repeat the GFR within 2 weeks to exclude causes of acute deterioration of GFR. For example, acute kidney injury or starting renin–angiotensin system antagonist therapy.
  
  Be aware that adults with CKD are at increased risk of progression to end stage renal disease if they have either of the following:
  
  a sustained decrease in GFR of 25% or more over 12 months or
  
  a sustained decrease in GFR of 15 ml/min or more over 12 months.
  
  When assessing CKD progression, extrapolate the current rate of decline of GFR and take this into account when planning intervention strategies, particularly if it suggests that the person might need renal replacement therapy in their lifetime.
  
  Risk factors associated with CKD progression in adults
  
  Work with adults who have any of the following risk factors for CKD progression to optimise their health:
  
  cardiovascular disease
  
  proteinuria
  
  acute kidney injury
  
  hypertension
  
  diabetes
  
  smoking
  
  African, African-Caribbean or Asian family origin
  
  chronic use of NSAIDs
  
  untreated urinary outflow tract obstruction.
  
  In adults with CKD the chronic use of NSAIDs may be associated with progression and acute use is associated with a reversible decrease in GFR. Exercise caution when treating people with CKD with NSAIDs over prolonged periods of time. Monitor the effects on GFR, particularly in people with a low baseline GFR and/or in the presence of other risks for progression.
  Indications for renal ultrasound in adults
  
  Offer a renal ultrasound scan to all adults with CKD who:
  
  have accelerated progression of CKD
  
  have visible or persistent invisible haematuria
  
  have symptoms of urinary tract obstruction
  
  have a family history of polycystic kidney disease and are older than 20
  
  have a GFR of less than 30 ml/min (GFR category G4 or G5)
  
  are considered by a nephrologist to need a renal biopsy.
  
  Advise adults with a family history of hereditary kidney disease about the implications of an abnormal result before a renal ultrasound scan is arranged for them.
  NICE DRAFT CKD 2021 – Referral criteria
  
  Refer adults with CKD for specialist assessment (taking into account their wishes and comorbidities) if they have any of the following:
  
  a 5-year risk of needing renal replacement therapy of greater than 5% (measured using the 4-variable Kidney Failure Risk Equation)
  
  an ACR of 70 mg/mmol or more, unless known to be caused by diabetes and already treated
  
  an ACR of 30 mg/mmol or more (ACR category A3), together with haematuria
  
  a sustained decrease in GFR of 25% or more and a change in GFR category within 12 months
  
  a sustained decrease in GFR of 15 ml/min or more per year
  
  hypertension that remains poorly controlled (above the person’s individual target) despite the use of at least 4 antihypertensive drugs at therapeutic doses
  
  known or suspected rare or genetic causes of CKD
  
  suspected renal artery stenosis.
  
  Consider discussing management with a specialist by letter, email or telephone if there are concerns but the person with CKD does not need to see a specialist.
  
  Refer people with CKD and renal outflow obstruction to urological services, unless urgent treatment is needed (for example, for hyperkalaemia, severe uraemia, acidosis or fluid overload).