Monitoring

Your Organizational Guidance

ebpracticenet urges you to prioritize the following organizational guidance:

Chronisch nierlijden (multidisciplinaire aanpak)Published by: WORELLast published: 2017GPC pluridisciplinaire sur la néphropathie chronique (IRC)Published by: Groupe de travail Développement de recommandations de première ligneLast published: 2017

Monitoring protocols are informed by patient factors.

Patients with risk factors for chronic kidney disease (CKD), such as diabetes, hypertension, or cardiovascular disease, should be screened using estimated glomerular filtration rate (eGFR; based on creatinine and, if available, cystatin C) and measurement of albuminuria (urine albumin to creatinine ratio).[77]​ See Screening.

Patients with CKD progression

Albuminuria and eGFR should be assessed at least annually in people with CKD, and more frequently for those at higher risk of progression.[1]​ Patients with CKD GFR category G3-G5 should be offered a risk assessment using a validated risk equation to estimate the risk of kidney failure.[1][137]

For patients with diabetes and CKD, the American Diabetes Association recommends monitoring with urinary albumin and eGFR 1-4 times per year, depending on the stage of disease (e.g., 1-2 times a year if G1 to G3a and normal or moderately increased albuminuria; 3-4 times a year if severely increased albuminuria or G4 or G5).[80]

Patients with anemia, secondary hyperparathyroidism, or metabolic acidosis

Patients with CKD without anemia should be regularly screened for anemia, with hemoglobin measured at least:[61][150]

  • annually for patients with GFR category G3 disease

  • twice a year for patients with G4 to G5 disease not on dialysis

  • every 3 months for patients with G5 disease on dialysis.

Patients who have CKD with anemia (not treated with an erythropoietin-stimulating agent) should be monitored with hemoglobin measured at least every 3 months for patients with G3 to G5 disease not on dialysis, and monthly for patients with G5 CKD on hemodialysis.[61]

Patients with GFR category G3 CKD should be monitored for mineral bone disorders with serum calcium and phosphorus measured at least every 6-12 months and intact parathyroid hormone (PTH) testing based on baseline level and CKD progression. For those with GFR category G4 disease, calcium and phosphorus should be measured every 3-6 months and intact PTH every 6-12 months. For patients with GFR category G5 CKD, calcium and phosphorus should be measured every 1-3 months and intact PTH every 3-6 months.[62]

Serum bicarbonate concentrations should be monitored for metabolic acidosis.[1]

Patients with diabetes

Glycemic goals should be individualized. Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommend an HbA1c target ranging from <6.5% to <8.0% for patients with diabetes and CKD not receiving dialysis. A lower target (e.g., <6.5% or <7.0%) may be appropriate for individuals in whom preventing complications is the key goal; a higher target (e.g., <7.5% or <8.0%) may be preferred in those with multimorbidity or increased burden of hypoglycemia.[92][93]

HbA1c should be checked at least twice per year in patients who are meeting their glycemic targets, or quarterly (four times per year) in patients who have recently changed drug therapy and/or who are not meeting glycemic targets.[92]

Patients with hypertension

An individualized approach should be used for blood pressure (BP) targets, taking into account age, comorbidities, risk of progression of CKD, and tolerance to treatments.[1]​ KDIGO guidelines suggest a target systolic BP of less than 120 mmHg, if tolerated, in patients with CKD, with and without diabetes, and not receiving dialysis.[1][81]​ Office BP measurement must be standardized when using this target. Less intensive BP-lowering therapy may be considered for specific patients, such as those with frailty, high risk of fracture and falls, postural hypotension, or limited life expectancy.[1] Certain guidelines advocate less intensive BP targets, which might be more achievable.[54][115]

KDIGO guidelines suggest considering:[81]

  • annual out-of-office BP assessment for patients not taking antihypertensive drugs with "white-coat" hypertension, and

  • checks at each primary care visit (with daily home BP monitoring for 1 week prior to the visit) for those taking antihypertensive drugs.

Patients with dyslipidemia

Total cholesterol and low-density lipoprotein treatment targets for patients with CKD have not been well established in clinical trials.

KDIGO guidelines recommend that CKD patients ≥50 years or those with a high risk of cardiovascular mortality (not on dialysis) should be treated with a statin without the need for routine follow-up to check lipid values, or to change treatment regimen based on set targets (i.e., a 'treat and forget' approach).[84]

Guidelines for patients with diabetic kidney disease recommend that lipids should be checked at diagnosis, and then annually. This may need to be done at more frequent intervals in patients on statins or other lipid-lowering therapy to check treatment goals; less frequent lipid monitoring may be appropriate for patients at lower cardiovascular risk (e.g., not on statins or lipid-lowering therapy, age <40 years).[201]​​

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