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Applying clinical guidelines –
treating and managing CKD

✓ Develop patient treatment plan according to level of severity.

CKD Classification and Staging

Source: Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney inter., Suppl. 2013; 3: 1-150.

Yellow Treatment Plan Recommendations1,2
eGFR ≥ 60 ml/min/1.73m2 with UACR 30-300 mg/g or eGFR 45-59 ml/min/1.73m2 with UACR < 30mg/g
Assessments
  • At least annual clinical review
  • Assess to rule out treatable kidney conditions
  • Assess/reduce risk for cardiovascular disease (CVD)
  • Assess for acute kidney injury (AKI)
  • Labs
    • UACR
    • Urea, creatinine, electrolytes
    • eGFR
    • HbA1c
    • Fasting lipids
Management
  • Evaluate/manage comorbid conditions
  • Individualize BP target
  • Avoid nephrotoxic medications
  • Prescribe ACEI or ARB – maximum tolerable doses
  • Target hemoglobin A1c ~ 7.0%
  • Target salt intake to < 2g per day
  • Prescribe lipid lowering medications as appropriate
  • Refer to renal dietitian
  • Teach patient self-management
Patient behavior and lifestyle
  • Increase physical activity
  • Maintain a healthy weight
  • Avoid tobacco products
Orange Treatment Plan Recommendations1,2
eGFR 30-59 ml/min/1.73m2 with UACR 30-300 mg/g or eGFR 30-44 ml/min/1.73m2 with UACR < 30mg/g
Assessments
  • 3-6 month clinical review
  • Assess to rule out treatable kidney conditions
  • Assess/reduce risk for CVD
  • Assess for AKI
  • Assess for complications – AKI, CVD, dyslipidemia, infections, anemia due to impaired erythropoiesis and low iron stores, hypertension, mineral imbalance and bone disorder (calcium, phosphorus, vitamin D)
  • Labs
    • UACR
    • Urea, creatinine, electrolytes
    • eGFR
    • HbA1c
    • Fasting lipids
    • CBC
    • Calcium, phosphate, and vitamin D
    • PTH if eGFR <45 mL/min/1.73m2
Management
  • Reduce progression of CKD
  • Evaluate/manage comorbid conditions
  • Evaluate/manage complications
  • Maintain BP target
  • Avoid nephrotoxic medications
  • Prescribe ACEI or ARB – adjust to levels of kidney function
  • Target hemoglobin A1c ~ 7.0%
  • Target salt intake to < 2g per day
  • Refer to renal dietitian for individualized diet
  • Teach patient self-management
  • Refer to social worker/case manager
  • Refer to nephrology as appropriate*
Patient behavior and lifestyle
  • Increase physical activity
  • Maintain a healthy weight
  • Avoid tobacco products
  • Eat a kidney-healthy diet as prescribed by a renal dietitian
Red Treatment Plan Recommendations1,2
eGFR < 30 ml/min/1.73m2 irrespective of albuminuria or UACR > 300mg/g irrespective of eGFR
Assessments
  • 1-3 month clinical review
  • Assess/reduce risk for CVD
  • Assess for complications – AKI, CVD, dyslipidemia, infections, anemia, hypertension, mineral imbalance and bone disorder, metabolic acidosis, malnutrition (low serum albumin), fluid and salt retention associated with accelerated hypertension
  • Labs
    • UACR
    • Urea, creatinine, electrolytes
    • eGFR
    • HbA1c
    • Fasting lipids
    • CBC
    • Calcium, phosphate, and vitamin D
    • PTH
Management
  • Reduce progression to ESRD
  • Treat comorbid conditions
  • Treat complications
  • Maintain target BP
  • Avoid nephrotoxic medications
  • Maintain target hemoglobin A1c ~ 7.0%
  • Refer to renal dietitian
  • Refer to social worker/case manager
  • Educate/prepare for RRT
  • Refer to nephrology at least 12 months prior to renal replacement therapy (RRT)
  • PCP continues to coordinate patient care
Patient behavior and lifestyle
  • Maintain physical activity as appropriate
  • Maintain a healthy weight
  • Avoid tobacco products
  • Eat a kidney-healthy diet as prescribed by a renal dietitian

✓ Consult, refer, and manage with nephrology when patient presents with:*

UACR Chart
  • eGFR and/or UACR that fall into the red zone.
  • AKI or abrupt sustained drop in eGFR.
  • Rapid progression as defined as a sustained declined in eGFR of more than 5 ml/min/1.73m2/yr.
  • RBC > 20 per high power field sustained and not readily explained.
  • Resistant hypertension refractory to treatment with 4 or more antihypertensive agents.
  • Persistent abnormalities of serum potassium.
  • Recurrent or extensive nephrolithiasis.
  • eGFR < 30 ml/min/1.73m2 in preparation for RRT.

✓ Manage patient with progressive CKD in a multidisciplinary care setting to include:

  • Primary and specialty care, health educator, and social worker/case manager.
  • Access to dietary counseling.
  • Education and counseling about different renal replacement therapy (RRT) modalities including transplantation options, hemodialysis, peritoneal dialysis, and options for vascular access surgery.
  • Conservative management for patients who choose not to receive RRT, to include protocols for pain management and psychological and spiritual care as desired.
  • Palliative and end-of-life care.

1 Adapted from CKD Management in General Practice, 2nd edition, Kidney Health Australia, Melbourne, 2012.

2 Adapted from Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2012 Clinical Practice Guidelines for the Evaluation and Management of Chronic Kidney Disease. Kidney Inter, Suppl. 2013; 3; 1-150.

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