Markers of kidney disease which may be present include:

• Proteinuria
• Haematuria (of presumed or proven renal origin)
• Structural abnormalities (e.g. reflux nephropathy, renal dysgenesis, medullary sponge kidney)
• A known diagnosis of a genetic kidney disease (e.g. polycystic kidney disease)
• Abnormalities detected by examination of renal histology
• Electrolyte abnormalities due to renal tubular disorders
• History of kidney transplantation

• Lifestyle Advice ^{NICE CKD 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 2021}
  • Give information about patients absolute risk and their 5-year risk of needing renal replacement therapy

    • The NICE guidance suggests 4-variable Kidney Failure Risk Equation
      • Here is a more intuitive calculator (NOT FROM OR APPROVED BY NICE GUIDANCE): kidneyfailurerisk.com
    • Use every day, jargon-free language to communicate information on risk. If technical terms are used, explain them clearly.
    • Set aside enough time during the consultation to give information on risk assessment and to answer any questions. Arrange another appointment for more discussion if this is needed.
    • Document the discussion on risk assessment and any decisions the person makes.
• Blood pressure control ^{NICE CKD 2021}
  • Aim for BP < 140/90

    • NICE CKD 2021 - Blood pressure control
      • In adults with CKD and an ACR under 70 mg/mmol, aim for a systolic blood pressure below 140 mmHg (target range 120 to 139 mmHg) and a diastolic blood pressure below 90 mmHg
  • Pharmacotherapy for hypertension: follow NICE guidelines for treatment of hypertension

    • NICE CKD DRAFT 2021 - Pharmacotherapy for hypertension
      • Follow the recommendations on treating hypertension in NICE’s guideline on hypertension in adults for adults with CKD, hypertension and an ACR of less than 30 mg/mmol (ACR categories A1 and A2).
• Pharmacotherapy for CKD ^{NICE CKD 2021}
  • For adults with CKD and diabetes (type 1 or type 2), offer an ACE inhibitor or an ARB and titrate to the optimal tolerated dose.

    For adults with CKD and diabetes (type 1 or type 2), offer:

    • an ACE inhibitor or an ARB if ACR is 3 mg/mmol or more

    Renin-angiotensin system antagonists

    • Check eGFR and potassium before initiation. Repeat 1 - 2 weeks after start and after each dose increase.
    • Do not routinely offer if pretreatment potassium > 5.0 mmol/l.
      • If an adult cannot use renin–angiotensin system antagonists because of hyperkalaemia:
        • assess for and treat any other factors that promote hyperkalaemia and
        • recheck serum potassium concentration.
    • STOP if potassium ≥ 6.0 mmol/l and other drugs known to promote hyperkalaemia have been discontinued.
    • If eGFR drop < 25% (or creatinine < 30%) repeat test in 1-2 weeks without modifying the renin–angiotensin system antagonist dose
    • If eGFR drop ≥ 25% (or creatinine ≥ 30%)
      • investigate other causes of a deterioration in renal function, such as volume depletion or concurrent medication (for example, NSAIDs)
      • 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.
  • SGLT2 inhibitors for Adults with CKD and type 2 diabetes

    NG28 Type 2 Diabetes and CKD

    • If ACR is ≥ 3mg/mmol Offer an ARB or ACEI (titrated to highest tolerated licensed dose)
    • Consider a licensed SGLT2i (in addition to the ARB or ACEI) if ACR is between 3 and 30 mg/mmol
  • Dapagliflozin for adults with CKD, with or without type 2 diabetes

    Dapagliflozin for treating CKD [TA775]
    Dapagliflozin is recommended as an option for treating CKD in adults. It is recommended only if:

    • it is an add-on to optimised standard care including the highest tolerated licensed dose of an ACEI or an ARB, unless these are contraindicated, and
    • people have an eGFR of 25 - 75 at the start of treatment and
      • have type 2 diabetes or
      • have a uACR of 22.6 mg/mmol or more.
  • For children and young people with CKD and diabetes (type 1 or type 2), offer an ACE inhibitor or an ARB and titrate to the optimal tolerated dose.

    For children and young people with CKD and diabetes (type 1 or 2), offer an ARB or an ACE inhibitor (titrated to the highest licensed dose that they can tolerate) if ACR is 3 mg/mmol or more.

    Renin-angiotensin system antagonists

    • Check eGFR and potassium before initiation. Repeat 1 - 2 weeks after start and after each dose increase.
    • Do not routinely offer if pretreatment potassium > 5.0 mmol/l.
      • If an adult cannot use renin–angiotensin system antagonists because of hyperkalaemia:
        • assess for and treat any other factors that promote hyperkalaemia and
        • recheck serum potassium concentration.
    • STOP if potassium ≥ 6.0 mmol/l and other drugs known to promote hyperkalaemia have been discontinued.
    • If eGFR drop < 25% (or creatinine < 30%) repeat test in 1-2 weeks without modifying the renin–angiotensin system antagonist dose
    • If eGFR drop ≥ 25% (or creatinine ≥ 30%)
      • investigate other causes of a deterioration in renal function, such as volume depletion or concurrent medication (for example, NSAIDs)
      • 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.
  • Frailty, comorbidities or other prescribed medications

    When offering medicines to lower proteinuria to people with frailty, comorbidities or who are taking many other prescribed medicines, follow the recommendations in NICE’s guideline on medicines optimisation to ensure the best possible outcomes. Seek specialist advice if needed, for example, from a consultant in care of the elderly.

• Statins for adults ^{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.

• Lifestyle Advice ^{NICE CKD 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 2021}
  • Give information about patients absolute risk and their 5-year risk of needing renal replacement therapy

    • The NICE guidance suggests 4-variable Kidney Failure Risk Equation
      • Here is a more intuitive calculator (NOT FROM OR APPROVED BY NICE GUIDANCE): kidneyfailurerisk.com
    • Use every day, jargon-free language to communicate information on risk. If technical terms are used, explain them clearly.
    • Set aside enough time during the consultation to give information on risk assessment and to answer any questions. Arrange another appointment for more discussion if this is needed.
    • Document the discussion on risk assessment and any decisions the person makes.
• Blood pressure control ^{NICE CKD 2021}
  • If ACR under 70 mg/mmol - Aim for BP < 140/90

    • NICE CKD 2021 - Blood pressure control
      • In adults with CKD and an ACR under 70 mg/mmol, aim for a systolic blood pressure below 140 mmHg (target range 120 to 139 mmHg) and a diastolic blood pressure below 90 mmHg
  • If ACR 70 mg/mmol or more - Aim for BP < 130/80

    • NICE CKD 2021 - Blood pressure control
      • In adults with CKD and an ACR of 70 mg/mmol or more, aim for a systolic blood pressure below 130 mmHg (target range 120 to 129 mmHg) and a diastolic blood pressure below 80 mmHg.
      • In children and young people with CKD and an ACR of 70 mg/mol or more, aim for a systolic blood pressure below the 50th percentile for height.
  • Pharmacotherapy for hypertension Offer an ACEI or an ARB

    • NICE CKD 2021 - Pharmacotherapy for hypertension
      • Offer an angiotensin-receptor blocker (ARB) or an angiotensin-converting enzyme (ACE) inhibitor to adults, children and young people with CKD who have hypertension and an ACR over 30 mg/mmol (ACR category A3 or above).
• Pharmacotherapy for CKD ^{NICE CKD 2021}
  • For adults with CKD and diabetes (type 1 or type 2), offer an ACE inhibitor or an ARB and titrate to the optimal tolerated dose.

    For adults with CKD and diabetes (type 1 or type 2), offer:

    • an ACE inhibitor or an ARB if ACR is 3 mg/mmol or more

    Renin-angiotensin system antagonists

    • Check eGFR and potassium before initiation. Repeat 1 - 2 weeks after start and after each dose increase.
    • Do not routinely offer if pretreatment potassium > 5.0 mmol/l.
      • If an adult cannot use renin–angiotensin system antagonists because of hyperkalaemia:
        • assess for and treat any other factors that promote hyperkalaemia and
        • recheck serum potassium concentration.
    • STOP if potassium ≥ 6.0 mmol/l and other drugs known to promote hyperkalaemia have been discontinued.
    • If eGFR drop < 25% (or creatinine < 30%) repeat test in 1-2 weeks without modifying the renin–angiotensin system antagonist dose
    • If eGFR drop ≥ 25% (or creatinine ≥ 30%)
      • investigate other causes of a deterioration in renal function, such as volume depletion or concurrent medication (for example, NSAIDs)
      • 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.
  • SGLT2 inhibitors for Adults with CKD and type 2 diabetes

    NG28 Type 2 Diabetes and CKD

    • If ACR is ≥ 3mg/mmol Offer an ARB or ACEI (titrated to highest tolerated licensed dose)
    • Offer a licensed SGLT2i (in addition to the ARB or ACEI) if ACR is over 30 mg/mmol
  • Dapagliflozin for adults with CKD, with or without type 2 diabetes

    Dapagliflozin for treating CKD [TA775]
    Dapagliflozin is recommended as an option for treating CKD in adults. It is recommended only if:

    • it is an add-on to optimised standard care including the highest tolerated licensed dose of an ACEI or an ARB, unless these are contraindicated, and
    • people have an eGFR of 25 - 75 at the start of treatment and
      • have type 2 diabetes or
      • have a uACR of 22.6 mg/mmol or more.
  • For children and young people with CKD and diabetes (type 1 or type 2), offer an ACE inhibitor or an ARB and titrate to the optimal tolerated dose.

    For children and young people with CKD and diabetes (type 1 or 2), offer an ARB or an ACE inhibitor (titrated to the highest licensed dose that they can tolerate) if ACR is 3 mg/mmol or more.

    Renin-angiotensin system antagonists

    • Check eGFR and potassium before initiation. Repeat 1 - 2 weeks after start and after each dose increase.
    • Do not routinely offer if pretreatment potassium > 5.0 mmol/l.
      • If an adult cannot use renin–angiotensin system antagonists because of hyperkalaemia:
        • assess for and treat any other factors that promote hyperkalaemia and
        • recheck serum potassium concentration.
    • STOP if potassium ≥ 6.0 mmol/l and other drugs known to promote hyperkalaemia have been discontinued.
    • If eGFR drop < 25% (or creatinine < 30%) repeat test in 1-2 weeks without modifying the renin–angiotensin system antagonist dose
    • If eGFR drop ≥ 25% (or creatinine ≥ 30%)
      • investigate other causes of a deterioration in renal function, such as volume depletion or concurrent medication (for example, NSAIDs)
      • 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.
  • Adults with CKD but without diabetes

    • refer for nephrology assessment and offer an ACE inhibitor or ARB, if ACR is 70 mg/mmol or more
    • Monitor if ACR is between 30 and 70 mg/mmol; consider discussing with a nephrologist if eGFR declines or ACR increases.
  • For children and young people with CKD but without diabetes

    • offer an ACE inhibitor or ARB, if ACR is 70 mg/mmol or more
    • Monitor if ACR is between 30 and 70 mg/mmol; consider discussing with a nephrologist if eGFR declines or ACR increases.
  • Frailty, comorbidities or other prescribed medications

    When offering medicines to lower proteinuria to people with frailty, comorbidities or who are taking many other prescribed medicines, follow the recommendations in NICE’s guideline on medicines optimisation to ensure the best possible outcomes. Seek specialist advice if needed, for example, from a consultant in care of the elderly.

• Statins for adults^{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.

Markers of kidney disease which may be present include:

• Proteinuria
• Haematuria (of presumed or proven renal origin)
• Structural abnormalities (e.g. reflux nephropathy, renal dysgenesis, medullary sponge kidney)
• A known diagnosis of a genetic kidney disease (e.g. polycystic kidney disease)
• Abnormalities detected by examination of renal histology
• Electrolyte abnormalities due to renal tubular disorders
• History of kidney transplantation

• Lifestyle Advice ^{NICE CKD 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 2021}
  • Give information about patients absolute risk and their 5-year risk of needing renal replacement therapy

    • The NICE guidance suggests 4-variable Kidney Failure Risk Equation
      • Here is a more intuitive calculator (NOT FROM OR APPROVED BY NICE GUIDANCE): kidneyfailurerisk.com
    • Use every day, jargon-free language to communicate information on risk. If technical terms are used, explain them clearly.
    • Set aside enough time during the consultation to give information on risk assessment and to answer any questions. Arrange another appointment for more discussion if this is needed.
    • Document the discussion on risk assessment and any decisions the person makes.
• Blood pressure control ^{NICE CKD 2021}
  • Aim for BP < 140/90

    • NICE CKD 2021 - Blood pressure control
      • In adults with CKD and an ACR under 70 mg/mmol, aim for a systolic blood pressure below 140 mmHg (target range 120 to 139 mmHg) and a diastolic blood pressure below 90 mmHg
  • Pharmacotherapy for hypertension: follow NICE guidelines for treatment of hypertension

    • NICE CKD DRAFT 2021 - Pharmacotherapy for hypertension
      • Follow the recommendations on treating hypertension in NICE’s guideline on hypertension in adults for adults with CKD, hypertension and an ACR of less than 30 mg/mmol (ACR categories A1 and A2).
• Pharmacotherapy for CKD ^{NICE CKD 2021}
  • For adults with CKD and diabetes (type 1 or type 2), offer an ACE inhibitor or an ARB and titrate to the optimal tolerated dose.

    For adults with CKD and diabetes (type 1 or type 2), offer:

    • an ACE inhibitor or an ARB if ACR is 3 mg/mmol or more

    Renin-angiotensin system antagonists

    • Check eGFR and potassium before initiation. Repeat 1 - 2 weeks after start and after each dose increase.
    • Do not routinely offer if pretreatment potassium > 5.0 mmol/l.
      • If an adult cannot use renin–angiotensin system antagonists because of hyperkalaemia:
        • assess for and treat any other factors that promote hyperkalaemia and
        • recheck serum potassium concentration.
    • STOP if potassium ≥ 6.0 mmol/l and other drugs known to promote hyperkalaemia have been discontinued.
    • If eGFR drop < 25% (or creatinine < 30%) repeat test in 1-2 weeks without modifying the renin–angiotensin system antagonist dose
    • If eGFR drop ≥ 25% (or creatinine ≥ 30%)
      • investigate other causes of a deterioration in renal function, such as volume depletion or concurrent medication (for example, NSAIDs)
      • 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.
  • SGLT2 inhibitors for Adults with CKD and type 2 diabetes

    NG28 Type 2 Diabetes and CKD

    • If ACR is ≥ 3mg/mmol Offer an ARB or ACEI (titrated to highest tolerated licensed dose)
    • Consider a licensed SGLT2i (in addition to the ARB or ACEI) if ACR is between 3 and 30 mg/mmol
  • Dapagliflozin for adults with CKD, with or without type 2 diabetes

    Dapagliflozin for treating CKD [TA775]
    Dapagliflozin is recommended as an option for treating CKD in adults. It is recommended only if:

    • it is an add-on to optimised standard care including the highest tolerated licensed dose of an ACEI or an ARB, unless these are contraindicated, and
    • people have an eGFR of 25 - 75 at the start of treatment and
      • have type 2 diabetes or
      • have a uACR of 22.6 mg/mmol or more.
  • For children and young people with CKD and diabetes (type 1 or type 2), offer an ACE inhibitor or an ARB and titrate to the optimal tolerated dose.

    For children and young people with CKD and diabetes (type 1 or 2), offer an ARB or an ACE inhibitor (titrated to the highest licensed dose that they can tolerate) if ACR is 3 mg/mmol or more.

    Renin-angiotensin system antagonists

    • Check eGFR and potassium before initiation. Repeat 1 - 2 weeks after start and after each dose increase.
    • Do not routinely offer if pretreatment potassium > 5.0 mmol/l.
      • If an adult cannot use renin–angiotensin system antagonists because of hyperkalaemia:
        • assess for and treat any other factors that promote hyperkalaemia and
        • recheck serum potassium concentration.
    • STOP if potassium ≥ 6.0 mmol/l and other drugs known to promote hyperkalaemia have been discontinued.
    • If eGFR drop < 25% (or creatinine < 30%) repeat test in 1-2 weeks without modifying the renin–angiotensin system antagonist dose
    • If eGFR drop ≥ 25% (or creatinine ≥ 30%)
      • investigate other causes of a deterioration in renal function, such as volume depletion or concurrent medication (for example, NSAIDs)
      • 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.
  • Frailty, comorbidities or other prescribed medications

    When offering medicines to lower proteinuria to people with frailty, comorbidities or who are taking many other prescribed medicines, follow the recommendations in NICE’s guideline on medicines optimisation to ensure the best possible outcomes. Seek specialist advice if needed, for example, from a consultant in care of the elderly.

• Statins for adults^{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.

• Lifestyle Advice ^{NICE CKD 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 2021}
  • Give information about patients absolute risk and their 5-year risk of needing renal replacement therapy

    • The NICE guidance suggests 4-variable Kidney Failure Risk Equation
      • Here is a more intuitive calculator (NOT FROM OR APPROVED BY NICE GUIDANCE): kidneyfailurerisk.com
    • Use every day, jargon-free language to communicate information on risk. If technical terms are used, explain them clearly.
    • Set aside enough time during the consultation to give information on risk assessment and to answer any questions. Arrange another appointment for more discussion if this is needed.
    • Document the discussion on risk assessment and any decisions the person makes.
• Blood pressure control ^{NICE CKD 2021}
  • If ACR under 70 mg/mmol - Aim for BP < 140/90

    • NICE CKD 2021 - Blood pressure control
      • In adults with CKD and an ACR under 70 mg/mmol, aim for a systolic blood pressure below 140 mmHg (target range 120 to 139 mmHg) and a diastolic blood pressure below 90 mmHg
  • If ACR 70 mg/mmol or more - Aim for BP < 130/80

    • NICE CKD 2021 - Blood pressure control
      • In adults with CKD and an ACR of 70 mg/mmol or more, aim for a systolic blood pressure below 130 mmHg (target range 120 to 129 mmHg) and a diastolic blood pressure below 80 mmHg.
      • In children and young people with CKD and an ACR of 70 mg/mol or more, aim for a systolic blood pressure below the 50th percentile for height.
  • Pharmacotherapy for hypertension Offer an ACEI or an ARB

    • NICE CKD 2021 - Pharmacotherapy for hypertension
      • Offer an angiotensin-receptor blocker (ARB) or an angiotensin-converting enzyme (ACE) inhibitor to adults, children and young people with CKD who have hypertension and an ACR over 30 mg/mmol (ACR category A3 or above).
• Pharmacotherapy for CKD ^{NICE CKD 2021}
  • For adults with CKD and diabetes (type 1 or type 2), offer an ACE inhibitor or an ARB and titrate to the optimal tolerated dose.

    For adults with CKD and diabetes (type 1 or type 2), offer:

    • an ACE inhibitor or an ARB if ACR is 3 mg/mmol or more

    Renin-angiotensin system antagonists

    • Check eGFR and potassium before initiation. Repeat 1 - 2 weeks after start and after each dose increase.
    • Do not routinely offer if pretreatment potassium > 5.0 mmol/l.
      • If an adult cannot use renin–angiotensin system antagonists because of hyperkalaemia:
        • assess for and treat any other factors that promote hyperkalaemia and
        • recheck serum potassium concentration.
    • STOP if potassium ≥ 6.0 mmol/l and other drugs known to promote hyperkalaemia have been discontinued.
    • If eGFR drop < 25% (or creatinine < 30%) repeat test in 1-2 weeks without modifying the renin–angiotensin system antagonist dose
    • If eGFR drop ≥ 25% (or creatinine ≥ 30%)
      • investigate other causes of a deterioration in renal function, such as volume depletion or concurrent medication (for example, NSAIDs)
      • 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.
  • SGLT2 inhibitors for Adults with CKD and type 2 diabetes

    NG28 Type 2 Diabetes and CKD

    • If ACR is ≥ 3mg/mmol Offer an ARB or ACEI (titrated to highest tolerated licensed dose)
    • Offer a licensed SGLT2i (in addition to the ARB or ACEI) if ACR is over 30 mg/mmol
  • Dapagliflozin for adults with CKD, with or without type 2 diabetes

    Dapagliflozin for treating CKD [TA775]
    Dapagliflozin is recommended as an option for treating CKD in adults. It is recommended only if:

    • it is an add-on to optimised standard care including the highest tolerated licensed dose of an ACEI or an ARB, unless these are contraindicated, and
    • people have an eGFR of 25 - 75 at the start of treatment and
      • have type 2 diabetes or
      • have a uACR of 22.6 mg/mmol or more.
  • For children and young people with CKD and diabetes (type 1 or type 2), offer an ACE inhibitor or an ARB and titrate to the optimal tolerated dose.

    For children and young people with CKD and diabetes (type 1 or 2), offer an ARB or an ACE inhibitor (titrated to the highest licensed dose that they can tolerate) if ACR is 3 mg/mmol or more.

    Renin-angiotensin system antagonists

    • Check eGFR and potassium before initiation. Repeat 1 - 2 weeks after start and after each dose increase.
    • Do not routinely offer if pretreatment potassium > 5.0 mmol/l.
      • If an adult cannot use renin–angiotensin system antagonists because of hyperkalaemia:
        • assess for and treat any other factors that promote hyperkalaemia and
        • recheck serum potassium concentration.
    • STOP if potassium ≥ 6.0 mmol/l and other drugs known to promote hyperkalaemia have been discontinued.
    • If eGFR drop < 25% (or creatinine < 30%) repeat test in 1-2 weeks without modifying the renin–angiotensin system antagonist dose
    • If eGFR drop ≥ 25% (or creatinine ≥ 30%)
      • investigate other causes of a deterioration in renal function, such as volume depletion or concurrent medication (for example, NSAIDs)
      • 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.
  • Adults with CKD but without diabetes

    • refer for nephrology assessment and offer an ACE inhibitor or ARB, if ACR is 70 mg/mmol or more
    • Monitor if ACR is between 30 and 70 mg/mmol; consider discussing with a nephrologist if eGFR declines or ACR increases.
  • For children and young people with CKD but without diabetes

    • offer an ACE inhibitor or ARB, if ACR is 70 mg/mmol or more
    • Monitor if ACR is between 30 and 70 mg/mmol; consider discussing with a nephrologist if eGFR declines or ACR increases.
  • Frailty, comorbidities or other prescribed medications

    When offering medicines to lower proteinuria to people with frailty, comorbidities or who are taking many other prescribed medicines, follow the recommendations in NICE’s guideline on medicines optimisation to ensure the best possible outcomes. Seek specialist advice if needed, for example, from a consultant in care of the elderly.

• Statins for adults^{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.

• Lifestyle Advice ^{NICE CKD 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 2021}
  • Give information about patients absolute risk and their 5-year risk of needing renal replacement therapy

    • The NICE guidance suggests 4-variable Kidney Failure Risk Equation
      • Here is a more intuitive calculator (NOT FROM OR APPROVED BY NICE GUIDANCE): kidneyfailurerisk.com
    • Use every day, jargon-free language to communicate information on risk. If technical terms are used, explain them clearly.
    • Set aside enough time during the consultation to give information on risk assessment and to answer any questions. Arrange another appointment for more discussion if this is needed.
    • Document the discussion on risk assessment and any decisions the person makes.
• Blood pressure control ^{NICE CKD 2021}
  • Aim for BP < 140/90

    • NICE CKD 2021 - Blood pressure control
      • In adults with CKD and an ACR under 70 mg/mmol, aim for a systolic blood pressure below 140 mmHg (target range 120 to 139 mmHg) and a diastolic blood pressure below 90 mmHg
  • Pharmacotherapy for hypertension: follow NICE guidelines for treatment of hypertension

    • NICE CKD DRAFT 2021 - Pharmacotherapy for hypertension
      • Follow the recommendations on treating hypertension in NICE’s guideline on hypertension in adults for adults with CKD, hypertension and an ACR of less than 30 mg/mmol (ACR categories A1 and A2).
• Pharmacotherapy for CKD ^{NICE CKD 2021}
  • Dapagliflozin for adults with CKD, with or without type 2 diabetes

    Dapagliflozin for treating CKD [TA775]
    Dapagliflozin is recommended as an option for treating CKD in adults. It is recommended only if:

    • it is an add-on to optimised standard care including the highest tolerated licensed dose of an ACEI or an ARB, unless these are contraindicated, and
    • people have an eGFR of 25 - 75 at the start of treatment and
      • have type 2 diabetes or
      • have a uACR of 22.6 mg/mmol or more.
  • Frailty, comorbidities or other prescribed medications

    When offering medicines to lower proteinuria to people with frailty, comorbidities or who are taking many other prescribed medicines, follow the recommendations in NICE’s guideline on medicines optimisation to ensure the best possible outcomes. Seek specialist advice if needed, for example, from a consultant in care of the elderly.

• Statins for adults^{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.

• Lifestyle Advice ^{NICE CKD 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 2021}
  • Give information about patients absolute risk and their 5-year risk of needing renal replacement therapy

    • The NICE guidance suggests 4-variable Kidney Failure Risk Equation
      • Here is a more intuitive calculator (NOT FROM OR APPROVED BY NICE GUIDANCE): kidneyfailurerisk.com
    • Use every day, jargon-free language to communicate information on risk. If technical terms are used, explain them clearly.
    • Set aside enough time during the consultation to give information on risk assessment and to answer any questions. Arrange another appointment for more discussion if this is needed.
    • Document the discussion on risk assessment and any decisions the person makes.
• Blood pressure control ^{NICE CKD 2021}
  • Aim for BP < 140/90

    • NICE CKD 2021 - Blood pressure control
      • In adults with CKD and an ACR under 70 mg/mmol, aim for a systolic blood pressure below 140 mmHg (target range 120 to 139 mmHg) and a diastolic blood pressure below 90 mmHg
  • Pharmacotherapy for hypertension: follow NICE guidelines for treatment of hypertension

    • NICE CKD DRAFT 2021 - Pharmacotherapy for hypertension
      • Follow the recommendations on treating hypertension in NICE’s guideline on hypertension in adults for adults with CKD, hypertension and an ACR of less than 30 mg/mmol (ACR categories A1 and A2).
• Pharmacotherapy for CKD ^{NICE CKD 2021}
  • For adults with CKD and diabetes (type 1 or type 2), offer an ACE inhibitor or an ARB and titrate to the optimal tolerated dose.

    For adults with CKD and diabetes (type 1 or type 2), offer:

    • an ACE inhibitor or an ARB if ACR is 3 mg/mmol or more

    Renin-angiotensin system antagonists

    • Check eGFR and potassium before initiation. Repeat 1 - 2 weeks after start and after each dose increase.
    • Do not routinely offer if pretreatment potassium > 5.0 mmol/l.
      • If an adult cannot use renin–angiotensin system antagonists because of hyperkalaemia:
        • assess for and treat any other factors that promote hyperkalaemia and
        • recheck serum potassium concentration.
    • STOP if potassium ≥ 6.0 mmol/l and other drugs known to promote hyperkalaemia have been discontinued.
    • If eGFR drop < 25% (or creatinine < 30%) repeat test in 1-2 weeks without modifying the renin–angiotensin system antagonist dose
    • If eGFR drop ≥ 25% (or creatinine ≥ 30%)
      • investigate other causes of a deterioration in renal function, such as volume depletion or concurrent medication (for example, NSAIDs)
      • 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.
  • SGLT2 inhibitors for Adults with CKD and type 2 diabetes

    NG28 Type 2 Diabetes and CKD

    • If ACR is ≥ 3mg/mmol Offer an ARB or ACEI (titrated to highest tolerated licensed dose)
    • Consider a licensed SGLT2i (in addition to the ARB or ACEI) if ACR is between 3 and 30 mg/mmol
  • Dapagliflozin for adults with CKD, with or without type 2 diabetes

    Dapagliflozin for treating CKD [TA775]
    Dapagliflozin is recommended as an option for treating CKD in adults. It is recommended only if:

    • it is an add-on to optimised standard care including the highest tolerated licensed dose of an ACEI or an ARB, unless these are contraindicated, and
    • people have an eGFR of 25 - 75 at the start of treatment and
      • have type 2 diabetes or
      • have a uACR of 22.6 mg/mmol or more.
  • For children and young people with CKD and diabetes (type 1 or type 2), offer an ACE inhibitor or an ARB and titrate to the optimal tolerated dose.

    For children and young people with CKD and diabetes (type 1 or 2), offer an ARB or an ACE inhibitor (titrated to the highest licensed dose that they can tolerate) if ACR is 3 mg/mmol or more.

    Renin-angiotensin system antagonists

    • Check eGFR and potassium before initiation. Repeat 1 - 2 weeks after start and after each dose increase.
    • Do not routinely offer if pretreatment potassium > 5.0 mmol/l.
      • If an adult cannot use renin–angiotensin system antagonists because of hyperkalaemia:
        • assess for and treat any other factors that promote hyperkalaemia and
        • recheck serum potassium concentration.
    • STOP if potassium ≥ 6.0 mmol/l and other drugs known to promote hyperkalaemia have been discontinued.
    • If eGFR drop < 25% (or creatinine < 30%) repeat test in 1-2 weeks without modifying the renin–angiotensin system antagonist dose
    • If eGFR drop ≥ 25% (or creatinine ≥ 30%)
      • investigate other causes of a deterioration in renal function, such as volume depletion or concurrent medication (for example, NSAIDs)
      • 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.
  • Frailty, comorbidities or other prescribed medications

    When offering medicines to lower proteinuria to people with frailty, comorbidities or who are taking many other prescribed medicines, follow the recommendations in NICE’s guideline on medicines optimisation to ensure the best possible outcomes. Seek specialist advice if needed, for example, from a consultant in care of the elderly.

• Statins for adults^{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.

• Lifestyle Advice ^{NICE CKD 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 2021}
  • Give information about patients absolute risk and their 5-year risk of needing renal replacement therapy

    • The NICE guidance suggests 4-variable Kidney Failure Risk Equation
      • Here is a more intuitive calculator (NOT FROM OR APPROVED BY NICE GUIDANCE): kidneyfailurerisk.com
    • Use every day, jargon-free language to communicate information on risk. If technical terms are used, explain them clearly.
    • Set aside enough time during the consultation to give information on risk assessment and to answer any questions. Arrange another appointment for more discussion if this is needed.
    • Document the discussion on risk assessment and any decisions the person makes.
• Blood pressure control ^{NICE CKD 2021}
  • If ACR under 70 mg/mmol - Aim for BP < 140/90

    • NICE CKD 2021 - Blood pressure control
      • In adults with CKD and an ACR under 70 mg/mmol, aim for a systolic blood pressure below 140 mmHg (target range 120 to 139 mmHg) and a diastolic blood pressure below 90 mmHg
  • If ACR 70 mg/mmol or more - Aim for BP < 130/80

    • NICE CKD 2021 - Blood pressure control
      • In adults with CKD and an ACR of 70 mg/mmol or more, aim for a systolic blood pressure below 130 mmHg (target range 120 to 129 mmHg) and a diastolic blood pressure below 80 mmHg.
      • In children and young people with CKD and an ACR of 70 mg/mol or more, aim for a systolic blood pressure below the 50th percentile for height.
  • Pharmacotherapy for hypertension Offer an ACEI or an ARB

    • NICE CKD 2021 - Pharmacotherapy for hypertension
      • Offer an angiotensin-receptor blocker (ARB) or an angiotensin-converting enzyme (ACE) inhibitor to adults, children and young people with CKD who have hypertension and an ACR over 30 mg/mmol (ACR category A3 or above).
• Pharmacotherapy for CKD ^{NICE CKD 2021}
  • For adults with CKD and diabetes (type 1 or type 2), offer an ACE inhibitor or an ARB and titrate to the optimal tolerated dose.

    For adults with CKD and diabetes (type 1 or type 2), offer:

    • an ACE inhibitor or an ARB if ACR is 3 mg/mmol or more

    Renin-angiotensin system antagonists

    • Check eGFR and potassium before initiation. Repeat 1 - 2 weeks after start and after each dose increase.
    • Do not routinely offer if pretreatment potassium > 5.0 mmol/l.
      • If an adult cannot use renin–angiotensin system antagonists because of hyperkalaemia:
        • assess for and treat any other factors that promote hyperkalaemia and
        • recheck serum potassium concentration.
    • STOP if potassium ≥ 6.0 mmol/l and other drugs known to promote hyperkalaemia have been discontinued.
    • If eGFR drop < 25% (or creatinine < 30%) repeat test in 1-2 weeks without modifying the renin–angiotensin system antagonist dose
    • If eGFR drop ≥ 25% (or creatinine ≥ 30%)
      • investigate other causes of a deterioration in renal function, such as volume depletion or concurrent medication (for example, NSAIDs)
      • 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.
  • SGLT2 inhibitors for Adults with CKD and type 2 diabetes

    NG28 Type 2 Diabetes and CKD

    • If ACR is ≥ 3mg/mmol Offer an ARB or ACEI (titrated to highest tolerated licensed dose)
    • Offer a licensed SGLT2i (in addition to the ARB or ACEI) if ACR is over 30 mg/mmol
  • Dapagliflozin for adults with CKD, with or without type 2 diabetes

    Dapagliflozin for treating CKD [TA775]
    Dapagliflozin is recommended as an option for treating CKD in adults. It is recommended only if:

    • it is an add-on to optimised standard care including the highest tolerated licensed dose of an ACEI or an ARB, unless these are contraindicated, and
    • people have an eGFR of 25 - 75 at the start of treatment and
      • have type 2 diabetes or
      • have a uACR of 22.6 mg/mmol or more.
  • For children and young people with CKD and diabetes (type 1 or type 2), offer an ACE inhibitor or an ARB and titrate to the optimal tolerated dose.

    For children and young people with CKD and diabetes (type 1 or 2), offer an ARB or an ACE inhibitor (titrated to the highest licensed dose that they can tolerate) if ACR is 3 mg/mmol or more.

    Renin-angiotensin system antagonists

    • Check eGFR and potassium before initiation. Repeat 1 - 2 weeks after start and after each dose increase.
    • Do not routinely offer if pretreatment potassium > 5.0 mmol/l.
      • If an adult cannot use renin–angiotensin system antagonists because of hyperkalaemia:
        • assess for and treat any other factors that promote hyperkalaemia and
        • recheck serum potassium concentration.
    • STOP if potassium ≥ 6.0 mmol/l and other drugs known to promote hyperkalaemia have been discontinued.
    • If eGFR drop < 25% (or creatinine < 30%) repeat test in 1-2 weeks without modifying the renin–angiotensin system antagonist dose
    • If eGFR drop ≥ 25% (or creatinine ≥ 30%)
      • investigate other causes of a deterioration in renal function, such as volume depletion or concurrent medication (for example, NSAIDs)
      • 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.
  • Adults with CKD but without diabetes

    • refer for nephrology assessment and offer an ACE inhibitor or ARB, if ACR is 70 mg/mmol or more
    • Monitor if ACR is between 30 and 70 mg/mmol; consider discussing with a nephrologist if eGFR declines or ACR increases.
  • For children and young people with CKD but without diabetes

    • offer an ACE inhibitor or ARB, if ACR is 70 mg/mmol or more
    • Monitor if ACR is between 30 and 70 mg/mmol; consider discussing with a nephrologist if eGFR declines or ACR increases.
  • Frailty, comorbidities or other prescribed medications

    When offering medicines to lower proteinuria to people with frailty, comorbidities or who are taking many other prescribed medicines, follow the recommendations in NICE’s guideline on medicines optimisation to ensure the best possible outcomes. Seek specialist advice if needed, for example, from a consultant in care of the elderly.

• Statins for adults^{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.

• Lifestyle Advice ^{NICE CKD 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 2021}
  • Give information about patients absolute risk and their 5-year risk of needing renal replacement therapy

    • The NICE guidance suggests 4-variable Kidney Failure Risk Equation
      • Here is a more intuitive calculator (NOT FROM OR APPROVED BY NICE GUIDANCE): kidneyfailurerisk.com
    • Use every day, jargon-free language to communicate information on risk. If technical terms are used, explain them clearly.
    • Set aside enough time during the consultation to give information on risk assessment and to answer any questions. Arrange another appointment for more discussion if this is needed.
    • Document the discussion on risk assessment and any decisions the person makes.
• Blood pressure control ^{NICE CKD 2021}
  • Aim for BP < 140/90

    • NICE CKD 2021 - Blood pressure control
      • In adults with CKD and an ACR under 70 mg/mmol, aim for a systolic blood pressure below 140 mmHg (target range 120 to 139 mmHg) and a diastolic blood pressure below 90 mmHg
  • Pharmacotherapy for hypertension: follow NICE guidelines for treatment of hypertension

    • NICE CKD DRAFT 2021 - Pharmacotherapy for hypertension
      • Follow the recommendations on treating hypertension in NICE’s guideline on hypertension in adults for adults with CKD, hypertension and an ACR of less than 30 mg/mmol (ACR categories A1 and A2).
• Pharmacotherapy for CKD ^{NICE CKD 2021}
  • Dapagliflozin for adults with CKD, with or without type 2 diabetes

    Dapagliflozin for treating CKD [TA775]
    Dapagliflozin is recommended as an option for treating CKD in adults. It is recommended only if:

    • it is an add-on to optimised standard care including the highest tolerated licensed dose of an ACEI or an ARB, unless these are contraindicated, and
    • people have an eGFR of 25 - 75 at the start of treatment and
      • have type 2 diabetes or
      • have a uACR of 22.6 mg/mmol or more.
  • Frailty, comorbidities or other prescribed medications

    When offering medicines to lower proteinuria to people with frailty, comorbidities or who are taking many other prescribed medicines, follow the recommendations in NICE’s guideline on medicines optimisation to ensure the best possible outcomes. Seek specialist advice if needed, for example, from a consultant in care of the elderly.

• Statins for adults^{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.

• Lifestyle Advice ^{NICE CKD 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 2021}
  • Give information about patients absolute risk and their 5-year risk of needing renal replacement therapy

    • The NICE guidance suggests 4-variable Kidney Failure Risk Equation
      • Here is a more intuitive calculator (NOT FROM OR APPROVED BY NICE GUIDANCE): kidneyfailurerisk.com
    • Use every day, jargon-free language to communicate information on risk. If technical terms are used, explain them clearly.
    • Set aside enough time during the consultation to give information on risk assessment and to answer any questions. Arrange another appointment for more discussion if this is needed.
    • Document the discussion on risk assessment and any decisions the person makes.
• Blood pressure control ^{NICE CKD 2021}
  • Aim for BP < 140/90

    • NICE CKD 2021 - Blood pressure control
      • In adults with CKD and an ACR under 70 mg/mmol, aim for a systolic blood pressure below 140 mmHg (target range 120 to 139 mmHg) and a diastolic blood pressure below 90 mmHg
  • Pharmacotherapy for hypertension: follow NICE guidelines for treatment of hypertension

    • NICE CKD DRAFT 2021 - Pharmacotherapy for hypertension
      • Follow the recommendations on treating hypertension in NICE’s guideline on hypertension in adults for adults with CKD, hypertension and an ACR of less than 30 mg/mmol (ACR categories A1 and A2).
• Pharmacotherapy for CKD ^{NICE CKD 2021}
  • For adults with CKD and diabetes (type 1 or type 2), offer an ACE inhibitor or an ARB and titrate to the optimal tolerated dose.

    For adults with CKD and diabetes (type 1 or type 2), offer:

    • an ACE inhibitor or an ARB if ACR is 3 mg/mmol or more

    Renin-angiotensin system antagonists

    • Check eGFR and potassium before initiation. Repeat 1 - 2 weeks after start and after each dose increase.
    • Do not routinely offer if pretreatment potassium > 5.0 mmol/l.
      • If an adult cannot use renin–angiotensin system antagonists because of hyperkalaemia:
        • assess for and treat any other factors that promote hyperkalaemia and
        • recheck serum potassium concentration.
    • STOP if potassium ≥ 6.0 mmol/l and other drugs known to promote hyperkalaemia have been discontinued.
    • If eGFR drop < 25% (or creatinine < 30%) repeat test in 1-2 weeks without modifying the renin–angiotensin system antagonist dose
    • If eGFR drop ≥ 25% (or creatinine ≥ 30%)
      • investigate other causes of a deterioration in renal function, such as volume depletion or concurrent medication (for example, NSAIDs)
      • 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.
  • SGLT2 inhibitors for Adults with CKD and type 2 diabetes

    NG28 Type 2 Diabetes and CKD

    • If ACR is ≥ 3mg/mmol Offer an ARB or ACEI (titrated to highest tolerated licensed dose)
    • Consider a licensed SGLT2i (in addition to the ARB or ACEI) if ACR is between 3 and 30 mg/mmol
  • Dapagliflozin for adults with CKD, with or without type 2 diabetes

    Dapagliflozin for treating CKD [TA775]
    Dapagliflozin is recommended as an option for treating CKD in adults. It is recommended only if:

    • it is an add-on to optimised standard care including the highest tolerated licensed dose of an ACEI or an ARB, unless these are contraindicated, and
    • people have an eGFR of 25 - 75 at the start of treatment and
      • have type 2 diabetes or
      • have a uACR of 22.6 mg/mmol or more.
  • For children and young people with CKD and diabetes (type 1 or type 2), offer an ACE inhibitor or an ARB and titrate to the optimal tolerated dose.

    For children and young people with CKD and diabetes (type 1 or 2), offer an ARB or an ACE inhibitor (titrated to the highest licensed dose that they can tolerate) if ACR is 3 mg/mmol or more.

    Renin-angiotensin system antagonists

    • Check eGFR and potassium before initiation. Repeat 1 - 2 weeks after start and after each dose increase.
    • Do not routinely offer if pretreatment potassium > 5.0 mmol/l.
      • If an adult cannot use renin–angiotensin system antagonists because of hyperkalaemia:
        • assess for and treat any other factors that promote hyperkalaemia and
        • recheck serum potassium concentration.
    • STOP if potassium ≥ 6.0 mmol/l and other drugs known to promote hyperkalaemia have been discontinued.
    • If eGFR drop < 25% (or creatinine < 30%) repeat test in 1-2 weeks without modifying the renin–angiotensin system antagonist dose
    • If eGFR drop ≥ 25% (or creatinine ≥ 30%)
      • investigate other causes of a deterioration in renal function, such as volume depletion or concurrent medication (for example, NSAIDs)
      • 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.
  • Frailty, comorbidities or other prescribed medications

    When offering medicines to lower proteinuria to people with frailty, comorbidities or who are taking many other prescribed medicines, follow the recommendations in NICE’s guideline on medicines optimisation to ensure the best possible outcomes. Seek specialist advice if needed, for example, from a consultant in care of the elderly.

• Statins for adults^{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.

• Lifestyle Advice ^{NICE CKD 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 2021}
  • Give information about patients absolute risk and their 5-year risk of needing renal replacement therapy

    • The NICE guidance suggests 4-variable Kidney Failure Risk Equation
      • Here is a more intuitive calculator (NOT FROM OR APPROVED BY NICE GUIDANCE): kidneyfailurerisk.com
    • Use every day, jargon-free language to communicate information on risk. If technical terms are used, explain them clearly.
    • Set aside enough time during the consultation to give information on risk assessment and to answer any questions. Arrange another appointment for more discussion if this is needed.
    • Document the discussion on risk assessment and any decisions the person makes.
• Blood pressure control ^{NICE CKD 2021}
  • If ACR under 70 mg/mmol - Aim for BP < 140/90

    • NICE CKD 2021 - Blood pressure control
      • In adults with CKD and an ACR under 70 mg/mmol, aim for a systolic blood pressure below 140 mmHg (target range 120 to 139 mmHg) and a diastolic blood pressure below 90 mmHg
  • If ACR 70 mg/mmol or more - Aim for BP < 130/80

    • NICE CKD 2021 - Blood pressure control
      • In adults with CKD and an ACR of 70 mg/mmol or more, aim for a systolic blood pressure below 130 mmHg (target range 120 to 129 mmHg) and a diastolic blood pressure below 80 mmHg.
      • In children and young people with CKD and an ACR of 70 mg/mol or more, aim for a systolic blood pressure below the 50th percentile for height.
  • Pharmacotherapy for hypertension Offer an ACEI or an ARB

    • NICE CKD 2021 - Pharmacotherapy for hypertension
      • Offer an angiotensin-receptor blocker (ARB) or an angiotensin-converting enzyme (ACE) inhibitor to adults, children and young people with CKD who have hypertension and an ACR over 30 mg/mmol (ACR category A3 or above).
• Pharmacotherapy for CKD ^{NICE CKD 2021}
  • For adults with CKD and diabetes (type 1 or type 2), offer an ACE inhibitor or an ARB and titrate to the optimal tolerated dose.

    For adults with CKD and diabetes (type 1 or type 2), offer:

    • an ACE inhibitor or an ARB if ACR is 3 mg/mmol or more

    Renin-angiotensin system antagonists

    • Check eGFR and potassium before initiation. Repeat 1 - 2 weeks after start and after each dose increase.
    • Do not routinely offer if pretreatment potassium > 5.0 mmol/l.
      • If an adult cannot use renin–angiotensin system antagonists because of hyperkalaemia:
        • assess for and treat any other factors that promote hyperkalaemia and
        • recheck serum potassium concentration.
    • STOP if potassium ≥ 6.0 mmol/l and other drugs known to promote hyperkalaemia have been discontinued.
    • If eGFR drop < 25% (or creatinine < 30%) repeat test in 1-2 weeks without modifying the renin–angiotensin system antagonist dose
    • If eGFR drop ≥ 25% (or creatinine ≥ 30%)
      • investigate other causes of a deterioration in renal function, such as volume depletion or concurrent medication (for example, NSAIDs)
      • 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.
  • SGLT2 inhibitors for Adults with CKD and type 2 diabetes

    NG28 Type 2 Diabetes and CKD

    • If ACR is ≥ 3mg/mmol Offer an ARB or ACEI (titrated to highest tolerated licensed dose)
    • Offer a licensed SGLT2i (in addition to the ARB or ACEI) if ACR is over 30 mg/mmol
  • Dapagliflozin for adults with CKD, with or without type 2 diabetes

    Dapagliflozin for treating CKD [TA775]
    Dapagliflozin is recommended as an option for treating CKD in adults. It is recommended only if:

    • it is an add-on to optimised standard care including the highest tolerated licensed dose of an ACEI or an ARB, unless these are contraindicated, and
    • people have an eGFR of 25 - 75 at the start of treatment and
      • have type 2 diabetes or
      • have a uACR of 22.6 mg/mmol or more.
  • For children and young people with CKD and diabetes (type 1 or type 2), offer an ACE inhibitor or an ARB and titrate to the optimal tolerated dose.

    For children and young people with CKD and diabetes (type 1 or 2), offer an ARB or an ACE inhibitor (titrated to the highest licensed dose that they can tolerate) if ACR is 3 mg/mmol or more.

    Renin-angiotensin system antagonists

    • Check eGFR and potassium before initiation. Repeat 1 - 2 weeks after start and after each dose increase.
    • Do not routinely offer if pretreatment potassium > 5.0 mmol/l.
      • If an adult cannot use renin–angiotensin system antagonists because of hyperkalaemia:
        • assess for and treat any other factors that promote hyperkalaemia and
        • recheck serum potassium concentration.
    • STOP if potassium ≥ 6.0 mmol/l and other drugs known to promote hyperkalaemia have been discontinued.
    • If eGFR drop < 25% (or creatinine < 30%) repeat test in 1-2 weeks without modifying the renin–angiotensin system antagonist dose
    • If eGFR drop ≥ 25% (or creatinine ≥ 30%)
      • investigate other causes of a deterioration in renal function, such as volume depletion or concurrent medication (for example, NSAIDs)
      • 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.
  • Adults with CKD but without diabetes

    • refer for nephrology assessment and offer an ACE inhibitor or ARB, if ACR is 70 mg/mmol or more
    • Monitor if ACR is between 30 and 70 mg/mmol; consider discussing with a nephrologist if eGFR declines or ACR increases.
  • For children and young people with CKD but without diabetes

    • offer an ACE inhibitor or ARB, if ACR is 70 mg/mmol or more
    • Monitor if ACR is between 30 and 70 mg/mmol; consider discussing with a nephrologist if eGFR declines or ACR increases.
  • Frailty, comorbidities or other prescribed medications

    When offering medicines to lower proteinuria to people with frailty, comorbidities or who are taking many other prescribed medicines, follow the recommendations in NICE’s guideline on medicines optimisation to ensure the best possible outcomes. Seek specialist advice if needed, for example, from a consultant in care of the elderly.

• Statins for adults^{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.

• Lifestyle Advice ^{NICE CKD 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 2021}
  • Give information about patients absolute risk and their 5-year risk of needing renal replacement therapy

    • The NICE guidance suggests 4-variable Kidney Failure Risk Equation
      • Here is a more intuitive calculator (NOT FROM OR APPROVED BY NICE GUIDANCE): kidneyfailurerisk.com
    • Use every day, jargon-free language to communicate information on risk. If technical terms are used, explain them clearly.
    • Set aside enough time during the consultation to give information on risk assessment and to answer any questions. Arrange another appointment for more discussion if this is needed.
    • Document the discussion on risk assessment and any decisions the person makes.
• Blood pressure control ^{NICE CKD 2021}
  • Aim for BP < 140/90

    • NICE CKD 2021 - Blood pressure control
      • In adults with CKD and an ACR under 70 mg/mmol, aim for a systolic blood pressure below 140 mmHg (target range 120 to 139 mmHg) and a diastolic blood pressure below 90 mmHg
  • Pharmacotherapy for hypertension: follow NICE guidelines for treatment of hypertension

    • NICE CKD DRAFT 2021 - Pharmacotherapy for hypertension
      • Follow the recommendations on treating hypertension in NICE’s guideline on hypertension in adults for adults with CKD, hypertension and an ACR of less than 30 mg/mmol (ACR categories A1 and A2).
• Pharmacotherapy for CKD ^{NICE CKD 2021}
  • Dapagliflozin for adults with CKD, with or without type 2 diabetes

    Dapagliflozin for treating CKD [TA775]
    Dapagliflozin is recommended as an option for treating CKD in adults. It is recommended only if:

    • it is an add-on to optimised standard care including the highest tolerated licensed dose of an ACEI or an ARB, unless these are contraindicated, and
    • people have an eGFR of 25 - 75 at the start of treatment and
      • have type 2 diabetes or
      • have a uACR of 22.6 mg/mmol or more.
  • Frailty, comorbidities or other prescribed medications

    When offering medicines to lower proteinuria to people with frailty, comorbidities or who are taking many other prescribed medicines, follow the recommendations in NICE’s guideline on medicines optimisation to ensure the best possible outcomes. Seek specialist advice if needed, for example, from a consultant in care of the elderly.

• Statins for adults^{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.

• Lifestyle Advice ^{NICE CKD 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 2021}
  • Give information about patients absolute risk and their 5-year risk of needing renal replacement therapy

    • The NICE guidance suggests 4-variable Kidney Failure Risk Equation
      • Here is a more intuitive calculator (NOT FROM OR APPROVED BY NICE GUIDANCE): kidneyfailurerisk.com
    • Use every day, jargon-free language to communicate information on risk. If technical terms are used, explain them clearly.
    • Set aside enough time during the consultation to give information on risk assessment and to answer any questions. Arrange another appointment for more discussion if this is needed.
    • Document the discussion on risk assessment and any decisions the person makes.
• Blood pressure control ^{NICE CKD 2021}
  • Aim for BP < 140/90

    • NICE CKD 2021 - Blood pressure control
      • In adults with CKD and an ACR under 70 mg/mmol, aim for a systolic blood pressure below 140 mmHg (target range 120 to 139 mmHg) and a diastolic blood pressure below 90 mmHg
  • Pharmacotherapy for hypertension: follow NICE guidelines for treatment of hypertension

    • NICE CKD DRAFT 2021 - Pharmacotherapy for hypertension
      • Follow the recommendations on treating hypertension in NICE’s guideline on hypertension in adults for adults with CKD, hypertension and an ACR of less than 30 mg/mmol (ACR categories A1 and A2).
• Pharmacotherapy for CKD ^{NICE CKD 2021}
  • For adults with CKD and diabetes (type 1 or type 2), offer an ACE inhibitor or an ARB and titrate to the optimal tolerated dose.

    For adults with CKD and diabetes (type 1 or type 2), offer:

    • an ACE inhibitor or an ARB if ACR is 3 mg/mmol or more

    Renin-angiotensin system antagonists

    • Check eGFR and potassium before initiation. Repeat 1 - 2 weeks after start and after each dose increase.
    • Do not routinely offer if pretreatment potassium > 5.0 mmol/l.
      • If an adult cannot use renin–angiotensin system antagonists because of hyperkalaemia:
        • assess for and treat any other factors that promote hyperkalaemia and
        • recheck serum potassium concentration.
    • STOP if potassium ≥ 6.0 mmol/l and other drugs known to promote hyperkalaemia have been discontinued.
    • If eGFR drop < 25% (or creatinine < 30%) repeat test in 1-2 weeks without modifying the renin–angiotensin system antagonist dose
    • If eGFR drop ≥ 25% (or creatinine ≥ 30%)
      • investigate other causes of a deterioration in renal function, such as volume depletion or concurrent medication (for example, NSAIDs)
      • 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.
  • SGLT2 inhibitors for Adults with CKD and type 2 diabetes

    NG28 Type 2 Diabetes and CKD

    • If ACR is ≥ 3mg/mmol Offer an ARB or ACEI (titrated to highest tolerated licensed dose)
    • Consider a licensed SGLT2i (in addition to the ARB or ACEI) if ACR is between 3 and 30 mg/mmol
  • Dapagliflozin for adults with CKD, with or without type 2 diabetes

    Dapagliflozin for treating CKD [TA775]
    Dapagliflozin is recommended as an option for treating CKD in adults. It is recommended only if:

    • it is an add-on to optimised standard care including the highest tolerated licensed dose of an ACEI or an ARB, unless these are contraindicated, and
    • people have an eGFR of 25 - 75 at the start of treatment and
      • have type 2 diabetes or
      • have a uACR of 22.6 mg/mmol or more.
  • For children and young people with CKD and diabetes (type 1 or type 2), offer an ACE inhibitor or an ARB and titrate to the optimal tolerated dose.

    For children and young people with CKD and diabetes (type 1 or 2), offer an ARB or an ACE inhibitor (titrated to the highest licensed dose that they can tolerate) if ACR is 3 mg/mmol or more.

    Renin-angiotensin system antagonists

    • Check eGFR and potassium before initiation. Repeat 1 - 2 weeks after start and after each dose increase.
    • Do not routinely offer if pretreatment potassium > 5.0 mmol/l.
      • If an adult cannot use renin–angiotensin system antagonists because of hyperkalaemia:
        • assess for and treat any other factors that promote hyperkalaemia and
        • recheck serum potassium concentration.
    • STOP if potassium ≥ 6.0 mmol/l and other drugs known to promote hyperkalaemia have been discontinued.
    • If eGFR drop < 25% (or creatinine < 30%) repeat test in 1-2 weeks without modifying the renin–angiotensin system antagonist dose
    • If eGFR drop ≥ 25% (or creatinine ≥ 30%)
      • investigate other causes of a deterioration in renal function, such as volume depletion or concurrent medication (for example, NSAIDs)
      • 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.
  • Frailty, comorbidities or other prescribed medications

    When offering medicines to lower proteinuria to people with frailty, comorbidities or who are taking many other prescribed medicines, follow the recommendations in NICE’s guideline on medicines optimisation to ensure the best possible outcomes. Seek specialist advice if needed, for example, from a consultant in care of the elderly.

• Statins for adults^{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.

• Lifestyle Advice ^{NICE CKD 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 2021}
  • Give information about patients absolute risk and their 5-year risk of needing renal replacement therapy

    • The NICE guidance suggests 4-variable Kidney Failure Risk Equation
      • Here is a more intuitive calculator (NOT FROM OR APPROVED BY NICE GUIDANCE): kidneyfailurerisk.com
    • Use every day, jargon-free language to communicate information on risk. If technical terms are used, explain them clearly.
    • Set aside enough time during the consultation to give information on risk assessment and to answer any questions. Arrange another appointment for more discussion if this is needed.
    • Document the discussion on risk assessment and any decisions the person makes.
• Blood pressure control ^{NICE CKD 2021}
  • If ACR under 70 mg/mmol - Aim for BP < 140/90

    • NICE CKD 2021 - Blood pressure control
      • In adults with CKD and an ACR under 70 mg/mmol, aim for a systolic blood pressure below 140 mmHg (target range 120 to 139 mmHg) and a diastolic blood pressure below 90 mmHg
  • If ACR 70 mg/mmol or more - Aim for BP < 130/80

    • NICE CKD 2021 - Blood pressure control
      • In adults with CKD and an ACR of 70 mg/mmol or more, aim for a systolic blood pressure below 130 mmHg (target range 120 to 129 mmHg) and a diastolic blood pressure below 80 mmHg.
      • In children and young people with CKD and an ACR of 70 mg/mol or more, aim for a systolic blood pressure below the 50th percentile for height.
  • Pharmacotherapy for hypertension Offer an ACEI or an ARB

    • NICE CKD 2021 - Pharmacotherapy for hypertension
      • Offer an angiotensin-receptor blocker (ARB) or an angiotensin-converting enzyme (ACE) inhibitor to adults, children and young people with CKD who have hypertension and an ACR over 30 mg/mmol (ACR category A3 or above).
• Pharmacotherapy for CKD ^{NICE CKD 2021}
  • For adults with CKD and diabetes (type 1 or type 2), offer an ACE inhibitor or an ARB and titrate to the optimal tolerated dose.

    For adults with CKD and diabetes (type 1 or type 2), offer:

    • an ACE inhibitor or an ARB if ACR is 3 mg/mmol or more

    Renin-angiotensin system antagonists

    • Check eGFR and potassium before initiation. Repeat 1 - 2 weeks after start and after each dose increase.
    • Do not routinely offer if pretreatment potassium > 5.0 mmol/l.
      • If an adult cannot use renin–angiotensin system antagonists because of hyperkalaemia:
        • assess for and treat any other factors that promote hyperkalaemia and
        • recheck serum potassium concentration.
    • STOP if potassium ≥ 6.0 mmol/l and other drugs known to promote hyperkalaemia have been discontinued.
    • If eGFR drop < 25% (or creatinine < 30%) repeat test in 1-2 weeks without modifying the renin–angiotensin system antagonist dose
    • If eGFR drop ≥ 25% (or creatinine ≥ 30%)
      • investigate other causes of a deterioration in renal function, such as volume depletion or concurrent medication (for example, NSAIDs)
      • 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.
  • SGLT2 inhibitors for Adults with CKD and type 2 diabetes

    NG28 Type 2 Diabetes and CKD

    • If ACR is ≥ 3mg/mmol Offer an ARB or ACEI (titrated to highest tolerated licensed dose)
    • Offer a licensed SGLT2i (in addition to the ARB or ACEI) if ACR is over 30 mg/mmol
  • Dapagliflozin for adults with CKD, with or without type 2 diabetes

    Dapagliflozin for treating CKD [TA775]
    Dapagliflozin is recommended as an option for treating CKD in adults. It is recommended only if:

    • it is an add-on to optimised standard care including the highest tolerated licensed dose of an ACEI or an ARB, unless these are contraindicated, and
    • people have an eGFR of 25 - 75 at the start of treatment and
      • have type 2 diabetes or
      • have a uACR of 22.6 mg/mmol or more.
  • For children and young people with CKD and diabetes (type 1 or type 2), offer an ACE inhibitor or an ARB and titrate to the optimal tolerated dose.

    For children and young people with CKD and diabetes (type 1 or 2), offer an ARB or an ACE inhibitor (titrated to the highest licensed dose that they can tolerate) if ACR is 3 mg/mmol or more.

    Renin-angiotensin system antagonists

    • Check eGFR and potassium before initiation. Repeat 1 - 2 weeks after start and after each dose increase.
    • Do not routinely offer if pretreatment potassium > 5.0 mmol/l.
      • If an adult cannot use renin–angiotensin system antagonists because of hyperkalaemia:
        • assess for and treat any other factors that promote hyperkalaemia and
        • recheck serum potassium concentration.
    • STOP if potassium ≥ 6.0 mmol/l and other drugs known to promote hyperkalaemia have been discontinued.
    • If eGFR drop < 25% (or creatinine < 30%) repeat test in 1-2 weeks without modifying the renin–angiotensin system antagonist dose
    • If eGFR drop ≥ 25% (or creatinine ≥ 30%)
      • investigate other causes of a deterioration in renal function, such as volume depletion or concurrent medication (for example, NSAIDs)
      • 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.
  • Adults with CKD but without diabetes

    • refer for nephrology assessment and offer an ACE inhibitor or ARB, if ACR is 70 mg/mmol or more
    • Monitor if ACR is between 30 and 70 mg/mmol; consider discussing with a nephrologist if eGFR declines or ACR increases.
  • For children and young people with CKD but without diabetes

    • offer an ACE inhibitor or ARB, if ACR is 70 mg/mmol or more
    • Monitor if ACR is between 30 and 70 mg/mmol; consider discussing with a nephrologist if eGFR declines or ACR increases.
  • Frailty, comorbidities or other prescribed medications

    When offering medicines to lower proteinuria to people with frailty, comorbidities or who are taking many other prescribed medicines, follow the recommendations in NICE’s guideline on medicines optimisation to ensure the best possible outcomes. Seek specialist advice if needed, for example, from a consultant in care of the elderly.

• Statins for adults^{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.

• Lifestyle Advice ^{NICE CKD 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 2021}
  • Give information about patients absolute risk and their 5-year risk of needing renal replacement therapy

    • The NICE guidance suggests 4-variable Kidney Failure Risk Equation
      • Here is a more intuitive calculator (NOT FROM OR APPROVED BY NICE GUIDANCE): kidneyfailurerisk.com
    • Use every day, jargon-free language to communicate information on risk. If technical terms are used, explain them clearly.
    • Set aside enough time during the consultation to give information on risk assessment and to answer any questions. Arrange another appointment for more discussion if this is needed.
    • Document the discussion on risk assessment and any decisions the person makes.
• Blood pressure control ^{NICE CKD 2021}
  • Aim for BP < 140/90

    • NICE CKD 2021 - Blood pressure control
      • In adults with CKD and an ACR under 70 mg/mmol, aim for a systolic blood pressure below 140 mmHg (target range 120 to 139 mmHg) and a diastolic blood pressure below 90 mmHg
  • Pharmacotherapy for hypertension: follow NICE guidelines for treatment of hypertension

    • NICE CKD DRAFT 2021 - Pharmacotherapy for hypertension
      • Follow the recommendations on treating hypertension in NICE’s guideline on hypertension in adults for adults with CKD, hypertension and an ACR of less than 30 mg/mmol (ACR categories A1 and A2).
• Statins for adults^{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.

• Lifestyle Advice ^{NICE CKD 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 2021}
  • Give information about patients absolute risk and their 5-year risk of needing renal replacement therapy

    • The NICE guidance suggests 4-variable Kidney Failure Risk Equation
      • Here is a more intuitive calculator (NOT FROM OR APPROVED BY NICE GUIDANCE): kidneyfailurerisk.com
    • Use every day, jargon-free language to communicate information on risk. If technical terms are used, explain them clearly.
    • Set aside enough time during the consultation to give information on risk assessment and to answer any questions. Arrange another appointment for more discussion if this is needed.
    • Document the discussion on risk assessment and any decisions the person makes.
• Blood pressure control ^{NICE CKD 2021}
  • Aim for BP < 140/90

    • NICE CKD 2021 - Blood pressure control
      • In adults with CKD and an ACR under 70 mg/mmol, aim for a systolic blood pressure below 140 mmHg (target range 120 to 139 mmHg) and a diastolic blood pressure below 90 mmHg
  • Pharmacotherapy for hypertension: follow NICE guidelines for treatment of hypertension

    • NICE CKD DRAFT 2021 - Pharmacotherapy for hypertension
      • Follow the recommendations on treating hypertension in NICE’s guideline on hypertension in adults for adults with CKD, hypertension and an ACR of less than 30 mg/mmol (ACR categories A1 and A2).
• Pharmacotherapy for CKD ^{NICE CKD 2021}
  • For adults with CKD and diabetes (type 1 or type 2), offer an ACE inhibitor or an ARB and titrate to the optimal tolerated dose.

    For adults with CKD and diabetes (type 1 or type 2), offer:

    • an ACE inhibitor or an ARB if ACR is 3 mg/mmol or more

    Renin-angiotensin system antagonists

    • Check eGFR and potassium before initiation. Repeat 1 - 2 weeks after start and after each dose increase.
    • Do not routinely offer if pretreatment potassium > 5.0 mmol/l.
      • If an adult cannot use renin–angiotensin system antagonists because of hyperkalaemia:
        • assess for and treat any other factors that promote hyperkalaemia and
        • recheck serum potassium concentration.
    • STOP if potassium ≥ 6.0 mmol/l and other drugs known to promote hyperkalaemia have been discontinued.
    • If eGFR drop < 25% (or creatinine < 30%) repeat test in 1-2 weeks without modifying the renin–angiotensin system antagonist dose
    • If eGFR drop ≥ 25% (or creatinine ≥ 30%)
      • investigate other causes of a deterioration in renal function, such as volume depletion or concurrent medication (for example, NSAIDs)
      • 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.
  • For children and young people with CKD and diabetes (type 1 or type 2), offer an ACE inhibitor or an ARB and titrate to the optimal tolerated dose.

    For children and young people with CKD and diabetes (type 1 or 2), offer an ARB or an ACE inhibitor (titrated to the highest licensed dose that they can tolerate) if ACR is 3 mg/mmol or more.

    Renin-angiotensin system antagonists

    • Check eGFR and potassium before initiation. Repeat 1 - 2 weeks after start and after each dose increase.
    • Do not routinely offer if pretreatment potassium > 5.0 mmol/l.
      • If an adult cannot use renin–angiotensin system antagonists because of hyperkalaemia:
        • assess for and treat any other factors that promote hyperkalaemia and
        • recheck serum potassium concentration.
    • STOP if potassium ≥ 6.0 mmol/l and other drugs known to promote hyperkalaemia have been discontinued.
    • If eGFR drop < 25% (or creatinine < 30%) repeat test in 1-2 weeks without modifying the renin–angiotensin system antagonist dose
    • If eGFR drop ≥ 25% (or creatinine ≥ 30%)
      • investigate other causes of a deterioration in renal function, such as volume depletion or concurrent medication (for example, NSAIDs)
      • 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.
  • Frailty, comorbidities or other prescribed medications

    When offering medicines to lower proteinuria to people with frailty, comorbidities or who are taking many other prescribed medicines, follow the recommendations in NICE’s guideline on medicines optimisation to ensure the best possible outcomes. Seek specialist advice if needed, for example, from a consultant in care of the elderly.

• Statins for adults^{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.

• Lifestyle Advice ^{NICE CKD 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 2021}
  • Give information about patients absolute risk and their 5-year risk of needing renal replacement therapy

    • The NICE guidance suggests 4-variable Kidney Failure Risk Equation
      • Here is a more intuitive calculator (NOT FROM OR APPROVED BY NICE GUIDANCE): kidneyfailurerisk.com
    • Use every day, jargon-free language to communicate information on risk. If technical terms are used, explain them clearly.
    • Set aside enough time during the consultation to give information on risk assessment and to answer any questions. Arrange another appointment for more discussion if this is needed.
    • Document the discussion on risk assessment and any decisions the person makes.
• Blood pressure control ^{NICE CKD 2021}
  • If ACR under 70 mg/mmol - Aim for BP < 140/90

    • NICE CKD 2021 - Blood pressure control
      • In adults with CKD and an ACR under 70 mg/mmol, aim for a systolic blood pressure below 140 mmHg (target range 120 to 139 mmHg) and a diastolic blood pressure below 90 mmHg
  • If ACR 70 mg/mmol or more - Aim for BP < 130/80

    • NICE CKD 2021 - Blood pressure control
      • In adults with CKD and an ACR of 70 mg/mmol or more, aim for a systolic blood pressure below 130 mmHg (target range 120 to 129 mmHg) and a diastolic blood pressure below 80 mmHg.
      • In children and young people with CKD and an ACR of 70 mg/mol or more, aim for a systolic blood pressure below the 50th percentile for height.
  • Pharmacotherapy for hypertension Offer an ACEI or an ARB

    • NICE CKD 2021 - Pharmacotherapy for hypertension
      • Offer an angiotensin-receptor blocker (ARB) or an angiotensin-converting enzyme (ACE) inhibitor to adults, children and young people with CKD who have hypertension and an ACR over 30 mg/mmol (ACR category A3 or above).
• Pharmacotherapy for CKD ^{NICE CKD 2021}
  • For adults with CKD and diabetes (type 1 or type 2), offer an ACE inhibitor or an ARB and titrate to the optimal tolerated dose.

    For adults with CKD and diabetes (type 1 or type 2), offer:

    • an ACE inhibitor or an ARB if ACR is 3 mg/mmol or more

    Renin-angiotensin system antagonists

    • Check eGFR and potassium before initiation. Repeat 1 - 2 weeks after start and after each dose increase.
    • Do not routinely offer if pretreatment potassium > 5.0 mmol/l.
      • If an adult cannot use renin–angiotensin system antagonists because of hyperkalaemia:
        • assess for and treat any other factors that promote hyperkalaemia and
        • recheck serum potassium concentration.
    • STOP if potassium ≥ 6.0 mmol/l and other drugs known to promote hyperkalaemia have been discontinued.
    • If eGFR drop < 25% (or creatinine < 30%) repeat test in 1-2 weeks without modifying the renin–angiotensin system antagonist dose
    • If eGFR drop ≥ 25% (or creatinine ≥ 30%)
      • investigate other causes of a deterioration in renal function, such as volume depletion or concurrent medication (for example, NSAIDs)
      • 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.
  • For children and young people with CKD and diabetes (type 1 or type 2), offer an ACE inhibitor or an ARB and titrate to the optimal tolerated dose.

    For children and young people with CKD and diabetes (type 1 or 2), offer an ARB or an ACE inhibitor (titrated to the highest licensed dose that they can tolerate) if ACR is 3 mg/mmol or more.

    Renin-angiotensin system antagonists

    • Check eGFR and potassium before initiation. Repeat 1 - 2 weeks after start and after each dose increase.
    • Do not routinely offer if pretreatment potassium > 5.0 mmol/l.
      • If an adult cannot use renin–angiotensin system antagonists because of hyperkalaemia:
        • assess for and treat any other factors that promote hyperkalaemia and
        • recheck serum potassium concentration.
    • STOP if potassium ≥ 6.0 mmol/l and other drugs known to promote hyperkalaemia have been discontinued.
    • If eGFR drop < 25% (or creatinine < 30%) repeat test in 1-2 weeks without modifying the renin–angiotensin system antagonist dose
    • If eGFR drop ≥ 25% (or creatinine ≥ 30%)
      • investigate other causes of a deterioration in renal function, such as volume depletion or concurrent medication (for example, NSAIDs)
      • 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.
  • Adults with CKD but without diabetes

    • refer for nephrology assessment and offer an ACE inhibitor or ARB, if ACR is 70 mg/mmol or more
    • Monitor if ACR is between 30 and 70 mg/mmol; consider discussing with a nephrologist if eGFR declines or ACR increases.
  • For children and young people with CKD but without diabetes

    • offer an ACE inhibitor or ARB, if ACR is 70 mg/mmol or more
    • Monitor if ACR is between 30 and 70 mg/mmol; consider discussing with a nephrologist if eGFR declines or ACR increases.
  • Frailty, comorbidities or other prescribed medications

    When offering medicines to lower proteinuria to people with frailty, comorbidities or who are taking many other prescribed medicines, follow the recommendations in NICE’s guideline on medicines optimisation to ensure the best possible outcomes. Seek specialist advice if needed, for example, from a consultant in care of the elderly.

• Statins for adults^{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.