ABSTRACT A panel of internists and nephrologists developed this practical approach for the Kidney Disease Outcomes Quality Initiative to guide assessment and care of chronic kidney disease (CKD) by primary care clinicians. Chronic kidney disease is defined as a glomerular filtration rate (GFR) 30 mg/g (>3 mg/mmol).3 In 2012 the Kidney Disease Improving Global Outcomes released a new guideline for chronic kidney disease that adds refinements based on cause, estimated glomerular filtration rate, and albuminuria categories (see Appendix A [available online] for guideline statements).4 Consideration of the cause of chronic kidney disease fundamentally affects management by distinguishing a systemic condition from one that is localized to the kidney, such as a glomerular disease. The albuminuria is complementary to low estimated glomerular filtration rate because both independently influence prognosis, as demonstrated by a heat map of the new classification illustrating an increasing risk of chronic kidney disease progression, morbidity, and mortality (Figure 1).4 This new grid offers a practical guide for primary care clinicians to inform monitoring and management of chronic kidney disease. The estimated prevalence of chronic kidney disease in the general population exceeds 10%,3,5 outstripping the availability of nephology specialists and requiring primary care clinicians to care for the majority of these patients. A panel of internists and nephrologists developed this practical approach to guide assessment and care of chronic kidney disease by primary care clinicians, described in the following sections on detection, progression, patient safety, interaction with cardiovascular disease, and nephrology referral. TOPIC 1: DETECTION OF CHRONIC KIDNEY DISEASE Overview Expert panels have identified insufficient evidence to support general population-based testing for chronic kidney disease.1,4,6-9 Both the Kidney Disease Outcomes Quality Initiative and the Kidney Disease Improving Global Outcomes chronic kidney disease guidelines have recommended targeted testing for chronic kidney disease among high-risk populations with diabetes and/or hypertension.1,4,9 In practice, detection of chronic kidney disease often occurs during routine care because serum creatinine testing is included in ubiquitous basic and comprehensive metabolic panels. Early detection of chronic kidney disease offers a valuate opportunity to avert complications before symptoms occur and to slow loss of kidney function over time.10-16 Compared with persons whose chronic kidney disease remains undetected, those with chronic kidney disease diagnosed by a primary care clinician are more likely to avoid risky use of nonsteroidal antiinflammatory drugs (NSAIDs)17; use angiotensin-converting-enzyme inhibitors (ACE-Is) or angiotensin receptor blockers (ARBs) when indicated17,18; and receive appropriate nephrology care.18 Kidney Function: Estimated Glomerular Filtration Rate Detection of chronic kidney disease based on estimated glomerular filtration rate is a more accurate assessment of kidney function than serum creatinine alone.1,4,9 Two equations are used in practice to estimate glomerular filtration rate, the Chronic Kidney DiseaseeEpidemiology Collaboration equation and the older Modification of Diet in Renal Disease Study equation. Recent studies have found that the Chronic Kidney DiseaseeEpidemiology Collaboration equation more accurately predicts prognosis and is less biased than the older Modification of Diet in Renal Disease Study equation.4,9,19 One caveat is that any estimated glomerular filtration rate equation is inaccurate in the setting of acute kidney injury because kidney function is not in a steady state. Urine Studies to Evaluate for Albuminuria or Proteinuria Although quantification of albuminuria has been less widely adopted in clinical practice than assessment of estimated glomerular filtration rate,5 it is crucial to evaluating prognosis. A spot albumin-to-creatinine ratio is a more sensitive and specific marker of chronic kidney disease than a spot urine protein/creatinine ratio, although both are predictive of clinical outcomes.9 Standardization of urine albumin measurement is ongoing but superior to urine protein that has much wider variability.9 A random or spot urine specimen quantifies albumin as milligrams per gram of creatinine (mg/g) (Figure 1).4 CLINICAL SIGNIFICANCE Chronic kidney disease (CKD) is defined by estimated glomerular filtration rate (eGFR) and urinary albumin/creatinine ratio. The 4 interventions that reduce CKD progression are blood pressure control 60 y of age, female gender, HTN, diabetes, CHF, volume depletion, active colitis, and medications that may predispose to AKI (RAAS blockers, diuretics, lithium and NSAIDs) Gabapentin Altered mental status, myoclonus, and asterixis with severe CKD GFR 30-59 mL/min/1.73 m2 : 200-700 mg twice daily GFR 15-29 mL/min/1.73 m2 : 200-700 mg daily GFR Canadians Seeking Solutions and Innovations to Overcome Chronic Kidney Disease (Can-SOLVE CKD): Form and Function Adeera Levin1,2 , Evan Adams1,3 , Brendan J. Barrett4 , Heather Beanlands5 , Kevin D. Burns6,7 , Helen Hoi-Lun Chiu2,8,9 , Kate Chong9 , Allison Dart10,11, Jack Ferera9 , Nicolas Fernandez12, Elisabeth Fowler13, Amit X. Garg14,15,