Patients with CKD stages 1 to 3a can be managed in primary care through the following domains:
Patient education on CKD (definition, current stage, health implications and likely prognosis), the possible causes and risk factors contributing to the patient's CKD, and how these can be further assessed and collaboratively managed. GPs may refer their patients to their PCN nurses to assist in patient education and counselling.
Optimising management of modifiable cause(s), risk factor(s) (including lifestyle modifications such as weight management, smoking cessation etc.) and comorbidities (including hypertension, dyslipidaemia, and diabetes).
Optimising management and initiating the necessary work-up for associated complications (e.g., anaemia, electrolyte abnormalities like hyperkalaemia and hyperphosphataemia, fluid retention, pericarditis etc.)
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Initiating patients on best medical therapy
Patients with CKD stage 3b to 5 should be referred to a nephrologist for consideration of shared care.
Considerations for Specialist Referral
There may be a subset of patients who present to primary care with new/established CKD that require more detailed and expedited assessment. Examples of such patients include those who first present with CKD stage 4 to 5 or individuals with findings suggestive of hydronephrosis on ultrasound kidneys.
Mainstay medications of choice for prevention of CKD progression
1. Angiotensin-Converting Enzyme Inhibitors (ACE-I) / Angiotensin Receptor Blockers (ARB)
These are the first-line anti-hypertensives that have been recommended to be initiated and titrated to the maximally tolerated doses in CKD patients with diabetes mellitus or CKD patients with the presence of albuminuria. These recommendations are consistent with
KDIGO,
NICE guidelines and ACE Clinical Guidance where ACE-I/ARB usage has been shown to improve kidney outcomes regardless of diabetic status. Concomitant use of both ACE-I and ARB should be avoided. Refer to the algorithm
for the approach to use of ACE-I/ARB for CKD patients. This is designed to be applied to both newly initiated and titration of ACE-I/ARB medications.
Dosing recommendations for ACE-I and ARB may be found within:
2. SGLT2 inhibitors
Initiation of SGLT2 inhibitors should be considered in patients with CKD (eGFR ≥ 20 ml/min/1.73m2) and persistent albuminuria as an adjunct to standard therapy to reduce the risk of sustained eGFR decline, end-stage renal failure, and cardiovascular death. It can be initiated in primary care for CKD in DM and non-DM patients.
Once started, it can be continued until
initiation of dialysis. Usage beyond this point is subject to clinical discretion by the attending nephrologist.
The glucose lowering efficacy of SGLT2 inhibitors is attenuated at eGFR < 45 ml/min/1.73m2, therefore it may be worth considering another additional agent for glucose-lowering effect. Independent of the reduced glucose lowering efficacy at this stage, SGLT2 inhibitors have reno-protective and cardio-protective effects.
The eGFR levels and starting dose for SGLT2 inhibitors for patients with CKD may be found within:
Practical advice before considering initiation/ increment of SGLT2 inhibitors:
eGFR may decline during the first 2-4 weeks after initiation of SGLT2 inhibitors. An initial rise of serum creatinine ≤ 30% is acceptable and SGLT2 inhibitors should not be discontinued, if haemodynamic instability and alternate causes of acute kidney injury (AKI) have been ruled out.
Ensure adequate hydration to minimise risk of euglycemic diabetic ketoacidosis (DKA).
Genital hygiene: Discuss risk for genitourinary tract infections and urinary tract infections.
Sick-day advice: Stop SGLT2 inhibitors 48 hours prior to surgery, during hospital admissions, and while acutely unwell, where there is risk of dehydration.
Consider reduction of concomitant diuretic usage or other anti-hypertensive medications (if risk of hypovolaemia) while keeping maximum tolerated ACE-I/ARB dose.
An algorithm detailing the use of ACE-I/ARB and SGLT2 inhibitors for CKD patients may be found here:
The role of non-steroidal mineralocorticoid receptor agonist can be found here:
Note: Please refer to
Healthier SG whitelist for the full list of subsidised drugs. Finerenone is not under the HSG Whitelist.
3. Common medications that should be prescribed with caution in patients with CKD
Many prescription medications are renally excreted and require dosing adjustments in patients with CKD. Extra caution should be exercised when prescribing such medications to prevent side effects and complications.
The list is not exhaustive: - Refer to package inserts for full details of medications.
Recommended Care Components
Recommended Care Components
|
Minimum Frequency* |
Remarks |
Blood Pressure Measurement |
Twice a year |
Targets based on recommendations under Risk Factor Control. |
Weight and BMI Assessment |
Twice a year |
Targets based on recommendations under Risk Factor Control. |
Lipid Profile |
Annually |
Targets based on recommendations under Risk Factor Control. |
Smoking Assessment |
Annually for smokers. Once-off for non-smokers unless there is a change in smoking habit. |
Assessment on smoking habits (estimated sticks/day; zero for non-or ex-smoker) and provision of smoking cessation counselling. |
Diabetes Screening |
Annually or once every three years, as clinically indicated |
Screening should be carried out every three years for those with normal glucose tolerance, and annually for those with impaired fasting glycaemia (IFG) or impaired glucose tolerance (IGT). Refer to
Diabetes Mellitus Care Protocol for diagnostic criteria. |
Kidney Function Monitoring |
Annually |
To include serum sodium, potassium, creatinine with eGFR. |
Urinary Protein |
Annually |
For patients who are currently diagnosed and managed for CKD, perform uACR as first line but to consider uPCR if uACR >30mg/mmol (300mg/g) or if non-albumin proteinuria is suspected.
Routine UFEME screening for RBC/WBC/Casts is
not recommended. To use clinical discretion in these cases. |
Full blood count |
Annually with eGFR 30-59 ml/min/1.73m2 and twice a year with < 30 ml/min/1.73m2) |
For patients with CKD stage G3aA2 or G1-3A3
To rule out causes of iron-deficiency anaemia before managing for anaemia of chronic disease. |
Albumin/calcium/phosphate |
Annually |
For patients with CKD stage G3aA3. |
Influenza Vaccination |
Annually or per season for:
|
As recommended under the National Adult Immunisation Schedule (NAIS). |
Pneumococcal Vaccination | 18 to 64 years of age: All persons aged 65 years and older:
| For further details on dose schedule for PCV13 and PPSV23 based on age and medical conditions, refer to:
|
COVID-19 Vaccination |
Two initial COVID-19 vaccine doses at an interval of eight weeks apart
An additional dose in 2024, around one year (and not earlier than five months) after the last dose received, is recommended for all persons aged 60 years and older, medically vulnerable individuals (e.g. chronic kidney conditions, including dialysis) and residents of aged care facilities. |
As recommended in MOH Circular No.12/2024 dated
29 February 2024. |
*More frequently if clinically indicated
Shared Care
Physicians should consider shared care with specialist services based on an individualised approach for patients. The usual indications for this are:
With later stages of CKD (e.g. CKD 3b to 5)
In whom a primary cause of CKD is suspected (e.g. glomerulonephritis or autoimmune diseases)
With nephrotic syndrome
Needing further diagnostic assessment (e.g. kidney biopsy)
With rapidly progressive CKD (i.e. a ≥ 25% decline in eGFR from baseline or > 5 mL/min/1.73m2/year decline)
With acute kidney injury (AKI)
With anaemia secondary to CKD
With resistant hypertension or refractory hypertension suspected to be secondary to CKD
With multiple comorbidities, such as heart failure or rheumatological conditions
With persistent hyperkalaemia
With bone disease or abnormal calcium metabolism
Special considerations
Acute kidney injury (AKI) and/or Acute on chronic kidney injury (AoCKD)
Acute kidney injury is defined by the following laboratory changes:
Increase in serum creatinine of ≥ 26.5 μmol/L (0.3 mg/dL) within 48 hours
Increase in serum creatinine ≥ 1.5 times of baseline which is known or presumed to have occurred within the past 7 days
Urine volume < 0.5 ml/kg/h for 6 hours
Clinicians should assess the patient holistically and perform the necessary clinical assessment in conjunction with laboratory investigations. While evaluating such patients for pre-renal, renal or post-renal causes, it is important to repeat the renal function as soon as practicable to assess for progression, stability, or resolution.
Patients with AoCKD may need to be referred for urgent evaluation in the presence of advanced CKD.
