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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Improving the understanding, detection, and management of kidney disease.

Evaluate Patients with CKD

Urine and blood tests are used to detect and monitor kidney disease. Currently, the key markers used include abnormal urine albumin levels and a persistent reduction in the estimated glomerular filtration rate (eGFR). Identification of the etiology may help guide management. Diabetes and hypertension are the leading causes of CKD in adults. Many diseases that cause kidney failure may have their origins in childhood. Early detection and appropriate treatment may improve prognosis in all age groups.

Identify Patients with CKD

Screen people at risk for CKD, including those with

The benefit of CKD screening in the general population is unclear.

The two key markers for CKD are urine albumin and eGFR. To screen for CKD:

CKD is generally diagnosed when there is evidence, for more than 3 months, of

Staging

Staging systems for chronic disease should identify risk for progression and complications. The current staging system for CKD, based exclusively on eGFR, does not appear to reliably identify those people at greatest risk for progression. Emerging research suggests an approach that includes multiple factors, such as urine albumin, age, and diabetes status may better predict progression.

In addition, the current staging requires accuracy of eGFR above 60 mL/min/1.73 m2. However, values above 60 calculated using the MDRD Study equation are not accurate. NKDEP encourages laboratories to report eGFR above 60 as "≥ 60" rather than as numerical values.

Although kidney function tends to decrease with age, this process has not been well investigated. Many people with age-related kidney function decline may not progress to kidney failure. Thus, the prognosis for a 75-year-old patient with an eGFR of 55 may be different than that for a 45-year-old patient with the same eGFR.

In addition, GFR may be too narrow a basis on which to assess risk for progression. The approach to staging is likely to evolve as it is informed by ongoing longitudinal research, e.g., the Chronic Renal Insufficiency Cohort Study.

Establish Cause of CKD

Because kidney damage is generally irreversible, it is important to identify the etiology as early as possible. Specific treatments are available in many cases (e.g., membraneous nephropathy, lupus nephropathy) and a diagnosis will guide management.

Although diabetes is the most common cause of CKD, it is important not to assume that a patient with diabetes and CKD has diabetic kidney disease. However, non-diabetic kidney disease is unlikely in a person with diabetes of long duration with other diabetic complications, physical findings of end-organ diabetic damage, and negative screening laboratory studies.

Suggested initial evaluation:

For further evaluation, the following tests are often ordered, depending on clinical presentation:

If a patient with diabetes has retinopathy, albuminuria, and negative screening tests listed above, it is reasonable to assume the diagnosis is diabetic kidney disease. Patients who do not conform to these criteria should be discussed with a nephrologist.

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References »

Astor BC, Hallan SI, Miller ER (3rd), Yeung E, Coresh J. Glomerular filtration rate, albuminuria, and risk of cardiovascular and all-cause mortality in the U.S. population. American Journal of Epidemiology. 2008; 167(10): 1226-1234.

Centers for Disease Control and Prevention. National Chronic Kidney Disease Fact Sheet: general information and national estimates on chronic kidney disease in the United States, 2010. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2010.
www.cdc.gov/diabetes/pubs/factsheets/kidney.htm

Coresh J, Selvin E, Stevens LA, et al. Prevalence of chronic kidney disease in the United States. Journal of the American Medical Association. 2007; 298(17):2038-2047.

Hemmelgarn BR, Manns BJ, Lloyd A, et al. Relation between kidney function, proteinuria, and adverse outcomes. Journal of the American Medical Association. 2010; 303(5): 423-429.

Lash JP, Go AS, Appel LJ, et al. Chronic Renal Insufficiency Cohort (CRIC) Study: baseline characteristics and associations with kidney function. Clinical Journal of the American Society of Nephrology. 2009;4(8):1302-1311.

Miller WG. Estimating glomerular filtration rate. Clinical Chemistry and Laboratory Medicine. 2009; 47:1017-1019.

Poggio ED, Nef PC, Wang X, et al. Performance of the Cockcroft-Gault and Modification of Diet in Renal Disease equations in estimating GFR in ill hospitalized patients. American Journal of Kidney Diseases. 2005; 46(2):242-252.

Schwartz GJ, Munoz A, Schneider MF, et al. New equations to estimate GFR in children with CKD. Journal of the American Society of Nephrology. 2009; 20(3): 629-637.

Schwartz GJ and Work DF. Measurement and estimation of GFR in children and adolescents. Clinical Journal of the American Society of Nephrology. 2009; 4 (11): 1832-1843.

Stevens LA, Coresh J, Feldman HI, et al. Evaluation of the Modification of Diet in Renal Disease study equation in a large diverse population. Journal of the American Society of Nephrology. 2007; 18(10):2749-2757.

Strippoli GFM, Bonifati C, Craig ME, Navaneethan SD, Craig JC. Angiotensin converting enzyme inhibitors and angiotensin II receptor antagonists for preventing progression of diabetic kidney disease (Review). The Cochrane Library 2010, Issue 4 (John Wiley & Sons, Ltd).

U.S. Renal Data System, USRDS 2010 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2010.

Verhave JC, Fesler P, Ribstein J, du Cailar G, Mimran A. Estimation of renal function in subjects with normal serum creatinine levels: influence of age and body mass index. American Journal of Kidney Diseases. 2005; 46(2):233-241.

Wrone EM, Carnethon MR, Palaniappan L, Fortmann SP. Association of dietary protein intake and microalbuminuria in healthy adults: Third National Health and Nutrition Examination Survey. American Journal of Kidney Diseases. 2003;41(3):580–587.

Evaluate Patients With CKD

Page last updated: March 28, 2012