1.7.0.0 Surveil­lance

Al­bu­min­uria and eGFR should be mon­i­tored reg­u­lar­ly to en­able time­ly di­ag­no­sis of CKD, mon­i­tor pro­gres­sion of CKD, de­tect su­per­im­posed kid­ney dis­eases in­clud­ing AKI, as­sess risk of CKD com­pli­ca­tions, dose drugs ap­pro­pri­ate­ly, and de­ter­mine whether nephrol­o­gy re­fer­ral is need­ed. Among peo­ple with ex­ist­ing kid­ney dis­ease, al­bu­minuria and eGFR may change due to pro­gres­sion of CKD, de­vel­op­ment of a sep­a­rate su­per­im­posed cause of kid­ney dis­ease, AKI, or other ef­fects of med­i­ca­tions, as noted above. Serum potas­si­um should also be mon­i­tored for pa­tients treat­ed with ACE in­hibitors, ARBs, and di­uret­ics be­cause these med­i­ca­tions can cause hy­per­kalemia or hy­pokalemia, which are as­so­ci­at­ed with car­dio­vas­cu­lar risk and mor­tal­i­ty (21-23). For pa­tients with eGFR <60 mL/‍min/‍1.73 m², ap­pro­pri­ate med­i­ca­tion dos­ing should be verified, ex­po­sure to nephro­tox­ins (e.g., non­s­teroidal anti-‍inflam­ma­to­ry drugs and io­d­i­nat­ed con­trast) should be min­i­mized, and po­ten­tial CKD com­pli­ca­tions should be eval­u­ated (Table 11.2).

The need for an­nu­al quan­ti­ta­tive as­sessment of al­bu­min ex­cre­tion after di­ag­no­sis of al­bu­minuria, in­sti­tu­tion of ACE in­hibitors or ARB ther­a­py, and achiev­ing blood pres­sure con­trol is a sub­ject of de­bate. Con­tin­ued surveil­lance can as­sess both re­sponse to ther­a­py and dis­ease pro­gres­sion and may aid in as­sessing ad­her­ence to ACE in­hibitor or ARB ther­a­py. In ad­di­tion, in clin­i­cal tri­als of ACE in­hibitors or ARB ther­a­py in type 2 di­a­betes, re­duc­ing al­bu­minuria from lev­els ≥300 mg/g Cr has been as­so­ci­at­ed with im­proved renal and car­dio­vas­cu­lar out­comes, lead­ing some to sug­gest that med­i­ca­tions should be titrat­ed to min­i­mize UACR. How­ev­er, this ap­proach has not been for­mal­ly eval­u­ated in prospec­tive tri­als. In type 1 di­a­betes, re­mis­sion of al­bu­minuria may occur spon­ta­neous­ly and co­hort stud­ies eval­u­at­ing as­so­ci­a­tions of change in al­bu­minuria with clin­i­cal out­comes have re­port­ed in­con­sis­tent re­sults (24,25).

The preva­lence of CKD com­pli­ca­tions cor­re­lates with eGFR (25a). When eGFR is <60 mL/‍min/‍1.73 m², screen­ing for com­pli­ca­tions of CKD is in­di­cat­ed (Table 11.2). Early vac­ci­na­tion against hep­ati­tis B virus is in­di­cat­ed in pa­tients like­ly to progress to ESRD (see Sec­tion 4 “Com­pre­hen­sive Med­i­cal Eval­u­a­tion and As­sess­ment of Co­mor­bidi­ties” for fur­ther in­for­ma­tion on im­mu­niza­tion).