Note from the Scottish Intercollegiate Guidelines Network (SIGN) and National Guideline Clearinghouse (NGC): In addition to these evidence-based recommendations, the guideline development group also identifies points of best clinical practice in the full-text guideline document.
The grades of recommendations (A–D) and levels of evidence (1++, 1+, 1-, 2++, 2+, 2-, 3, 4) are defined at the end of the "Major Recommendations" field.
Risk Factors, Diagnosis and Classification
Detection of Individuals at Higher Risk of Developing Chronic Kidney Disease
Diabetes Mellitus
D - All patients with diabetes should have regular surveillance of renal function.
Smoking
C - Smoking should be considered as a risk factor for the development of chronic kidney disease.
Obesity and Socioeconomic Status
C - Low socioeconomic status should be considered as a risk factor for the development of chronic kidney disease.
Detecting Kidney Damage
Proteinuria
B - In patients with diabetes, albumin/creatinine ratio may be used to exclude diabetic nephropathy.
C - Albumin/creatinine ratio is recommended for detecting and monitoring diabetic nephropathy.
B - In patient groups with a high prevalence of proteinuria without diabetes, protein/creatinine ratio may be used to exclude chronic kidney disease.
D - In patients with established chronic kidney disease and without diabetes, measurement of protein/creatinine ratio may be used to predict risk of progressive disease.
Haematuria
D - Patients with persisting isolated microscopic haematuria should be initially evaluated for urinary tract infection and malignancy.
Comparing Renal Function Tests
C - Where an assessment of glomerular filtration rate is required prediction equations should be used in preference to 24-hour urine creatinine clearance or serum creatinine alone.
Treatment
Lowering Blood Pressure
A - Blood pressure should be controlled to slow the deterioration of glomerular filtration rate and reduce proteinuria. Patients with ≥1 g/day of proteinuria (approximately equivalent to a protein/creatinine ratio of 100 mg/mmol) should have a target maximum systolic blood pressure of 130 mmHg.
Reducing Proteinuria
A - Patients with chronic kidney disease and proteinuria should be treated to reduce proteinuria.
Angiotensin Converting Enzyme (ACE) Inhibitors and Angiotensin Receptor Blockers (ARBs)
Reducing the Progression of Chronic Kidney Disease
Progression of Microalbuminuria to Macroalbuminuria in Diabetes Mellitus
A - Patients with chronic kidney disease and type 1 diabetes with microalbuminuria should be treated with an ACE inhibitor irrespective of blood pressure.
A - Patients with chronic kidney disease and type 2 diabetes with microalbuminuria should be treated with an ACE inhibitor or an ARB irrespective of blood pressure.
Proteinuria Reduction in Non-diabetic Patients with Chronic Kidney Disease
A - ACE inhibitors and ARBs are the agents of choice to reduce proteinuria in patients without diabetes but who have chronic kidney disease and proteinuria.
Combination Treatment with ACE Inhibitors and ARBs
A - ACE inhibitors and/or ARBs should be used as agents of choice in patients (with or without diabetes) with chronic kidney disease and proteinuria (≥0.5 g/day, approximately equivalent to a protein/creatinine ratio of 50 mg/mmol) in order to reduce the rate of progression of chronic kidney disease.
Non-Dihydropyridine Calcium Channel Blockers
Reducing the Progression of Chronic Kidney Disease
A - Non-dihydropyridine calcium channel blockers should be considered in patients with chronic kidney disease and proteinuria who are intolerant of ACE inhibitors or ARBs.
Lipid Lowering
Reducing the Risk of Cardiovascular Disease
B - Statin therapy should be considered in all patients with stage 1-3 chronic kidney disease, with a predicted 10-year cardiovascular risk ≥ 20%.
Antiplatelet Therapy
Reducing the Risk of Cardiovascular Disease
B - Low-dose antiplatelet therapy should be considered in all patients with stage 1-3 chronic kidney disease, whose estimated 10-year cardiovascular risk is ≥ 20%.
Dietary Modification
Reducing the Progression of Chronic Kidney Disease
Protein Restrictions
A - Dietary protein restrictions (<0.8 g/kg/day) are not recommended in patients with early stages of chronic kidney disease (stages 1-3).
Reducing the Risk of Cardiovascular Disease
B - For patients with stage 1-4 chronic kidney disease and hypertension a reduction in sodium (<2.4 g/day or <100 mmol/day which is equivalent to <6 g of salt) is recommended as part of a comprehensive strategy to lower blood pressure and reduce cardiovascular risk.
Treatments to Improve Quality of Life
Psychosocial Management
Patient Education
B - The delivery of a psychologically informed, pre-dialysis psychoeducation programme is recommended for all patients with progressive chronic kidney disease at any stage who will eventually require renal replacement therapy.
Erythropoiesis Stimulating Agents in the Management of Anaemia
A - Erythropoiesis stimulating agents should be considered in all patients with anaemia of chronic kidney disease to improve their quality of life.
Preventing Malnutrition
D - Nutritional status (height, weight, body mass index, percentage weight loss) should be monitored in all patients with chronic kidney disease at stage 3 or higher.
Definitions:
Levels of Evidence
1++: High quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs with a very low risk of bias
1+: Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias
1-: Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias
2++: High quality systematic reviews of case control or cohort studies
High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal
2+: Well-conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal
2-: Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal
3: Non-analytic studies (e.g., case reports, case series)
4: Expert opinion
Grades of Recommendation
Note: The grade of recommendation relates to the strength of the evidence on which the recommendation is based. It does not reflect the clinical importance of the recommendation.
A: At least one meta-analysis, systematic review of RCTs, or RCT rated as 1++ and directly applicable to the target population; or
A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results
B: A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
C: A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
D: Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
