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A-Z Frankston-Mornington Peninsula local pathways > Chronic Kidney Disease > Chronic kidney disease
DEFINITION OF CKD
eGFR<60 mL/min/1.73
m2 and/or evidence of
kidney damage for at
least 3 months
Classify stage
according to eGFR
and structural renal
disease
Management
REFERRAL
Monitoring Monitoring Nephrologist
Preemptive
Lipid lowering and Common drugs to Transplantation
Blood pressure Anaemia management
reduction glycaemic control avoid
Renal management
BP lowering agents towards the end of life
Advanced Care
REFERRAL Planning
Nephrologists
Published: 01-Jul-2016 Valid until: 17-Nov-2017 Printed on: 20-Dec-2017 © Map of Medicine Ltd
This care map was published by Frankston MorningtonPsula. A printed version of this document is not controlled so may not be up-to-date
with the latest clinical information.
Page 1 of 13
Chronic kidney disease management − primary care
A-Z Frankston-Mornington Peninsula local pathways > Chronic Kidney Disease > Chronic kidney disease
Published: 01-Jul-2016 Valid until: 17-Nov-2017 Printed on: 20-Dec-2017 © Map of Medicine Ltd
This care map was published by Frankston MorningtonPsula. A printed version of this document is not controlled so may not be up-to-date
with the latest clinical information.
Page 2 of 13
Chronic kidney disease management − primary care
A-Z Frankston-Mornington Peninsula local pathways > Chronic Kidney Disease > Chronic kidney disease
References
[1] Chronic Kidney Disease (CKD) Management in General Practice (2nd edition). Kidney Health Australia,
Melbourne, 2012.
See the Kidney Health Australia colour coded staging diagram for more information.
Reference
[1] Chronic Kidney Disease (CKD) Management in General Practice (2nd edition). Kidney Health Australia,Melbourne, 2012.
13 Goals of management
Quick info:
Goals of management [1]
• appropriate referral to a Nephrologist
2
• prepare for dialysis or preemptive transplant if eGFR <30 mL/min/1.73m
• discuss advanced care directive
• reduce progression of kidney disease
Published: 01-Jul-2016 Valid until: 17-Nov-2017 Printed on: 20-Dec-2017 © Map of Medicine Ltd
This care map was published by Frankston MorningtonPsula. A printed version of this document is not controlled so may not be up-to-date
with the latest clinical information.
Page 3 of 13
Chronic kidney disease management − primary care
A-Z Frankston-Mornington Peninsula local pathways > Chronic Kidney Disease > Chronic kidney disease
References
[1] Chronic Kidney Disease (CKD) Management in General Practice (2nd edition). Kidney Health Australia,Melbourne, 2012.
14 Goals of management
Quick info:
Goals of management
• establish diagnosis of kidney disease and exclude treatable kidney disease
• assessment and management of cardiovascular risk
• reduce rate of CKD progression
• consider earlier referral to nephrologist for younger people or people with significant decrease in renal function over 6 weeks
References
[1] Chronic Kidney Disease (CKD) Management in General Practice (2nd edition). Kidney Health Australia,Melbourne, 2012.
15 Goals of management
Quick info:
Goals of management
• investigations to exclude treatable disease
• reduce progression of kidney disease
• reduce CVD risk
• early detection and management of complications
• avoidance of nephrotoxic medications or volume depletion
• adjustment of medication doses to levels appropriate for kidney function
• consider earlier referral to nephrologist for younger people or people with significant decrease in renal function over 6 weeks
• consider discussing advanced care directive
References
[1] Chronic Kidney Disease (CKD) Management in General Practice (2nd edition). Kidney Health Australia,Melbourne, 2012.
16 REFERRAL Nephrologist
Quick info:
Referral to a Nephrologist
Everyone in this category should be referred to a nephrologist (unless limited life expectancy for other reasons)
• The KHA-CARI guidelines recommend that individuals should be referred to a Nephrologist at least 12 months prior to the
2
anticipated commencement of dialysis and/or kidney transplantation (i.e. referral when eGFR <30 mL/min/1.73m
Published: 01-Jul-2016 Valid until: 17-Nov-2017 Printed on: 20-Dec-2017 © Map of Medicine Ltd
This care map was published by Frankston MorningtonPsula. A printed version of this document is not controlled so may not be up-to-date
with the latest clinical information.
Page 4 of 13
Chronic kidney disease management − primary care
A-Z Frankston-Mornington Peninsula local pathways > Chronic Kidney Disease > Chronic kidney disease
• Ca
• Po4
• ESR
• CRP
• Uric acid
• Full blood count
• PTH
• vit D
• Iron studies
• Renal ultrasound
• 24 hour urine protein and sodium excretion (if macroalbuminuria)
Peninsula Health
Frankston Hospital CKD clinic
Ph: (03) 9784 7243
Fax: (03) 9784 7289
The Department of Nephrology provides inpatient care, acute dialysis and consultation for all patients admitted to Frankston Hospital
with kidney problems.
In addition, the department provides a range of outpatient clinics for chronic kidney disease, haemodialysis, peritoneal dialysis and
transplant patients.
Private nephrologists
Nephrologist listings from National Health Service Directory
Details of relevant service providers are listed as a service for clinicians. Listing in this pathway is not an endorsement of the
provider. If any relevant providers have been missed or if information is incorrect, please use the feedback button on the bottom right
of the page to alert us.
References
[1] Chronic Kidney Disease (CKD) Management in General Practice (2nd edition). Kidney Health Australia,Melbourne, 2012.
Published: 01-Jul-2016 Valid until: 17-Nov-2017 Printed on: 20-Dec-2017 © Map of Medicine Ltd
This care map was published by Frankston MorningtonPsula. A printed version of this document is not controlled so may not be up-to-date
with the latest clinical information.
Page 5 of 13
Chronic kidney disease management − primary care
A-Z Frankston-Mornington Peninsula local pathways > Chronic Kidney Disease > Chronic kidney disease
17 Monitoring
Quick info:
Monitoring
• 6-12 monthly clinical review
• clinical assessment
• blood pressure
• weight
laboratory assessment
• urine ACR
• biochemical profile including urea, creatinine and electrolytes
• eGFR
• HbA1c (for people with diabetes)
• fasting lipids
References
[1] Chronic Kidney Disease (CKD) Management in General Practice (2nd edition). Kidney Health Australia,Melbourne, 2012.
18 Monitoring
Quick info:
Monitoring
• 3-6 monthly clinical review
• clinical assessment
• blood pressure
• weight
• laboratory assessment
• urine ACR
• biochemical profile including urea, creatinine and electrolytes
• eGFR
• HbA1c (for people with diabetes)
• fasting lipids
• full blood count
• calcium and phosphate
2
• parathyroid hormone (6-12 monthly if eGFR < 45 mL/min/1.73m )
References
[1] Chronic Kidney Disease (CKD) Management in General Practice (2nd edition). Kidney Health Australia,Melbourne, 2012.
Published: 01-Jul-2016 Valid until: 17-Nov-2017 Printed on: 20-Dec-2017 © Map of Medicine Ltd
This care map was published by Frankston MorningtonPsula. A printed version of this document is not controlled so may not be up-to-date
with the latest clinical information.
Page 6 of 13
Chronic kidney disease management − primary care
A-Z Frankston-Mornington Peninsula local pathways > Chronic Kidney Disease > Chronic kidney disease
References
[1] Chronic Kidney Disease (CKD) Management in General Practice (2nd edition). Kidney Health Australia,Melbourne, 2012.
21 Monitoring
Quick info:
Monitoring
• 1-3 monthly clinical review
• clinical assessment
• blood pressure
• weight
• oedema
• laboratory assessment
• urine ACR
• biochemical profile including urea, creatinine and electrolytes
• eGFR
• HbA1c (for people with diabetes)
• fasting lipids
• full blood count (if anaemic see Page 30)
• calcium and phosphate
• parathyroid hormone (6-12 monthly if eGFR < 45 mL/min/1.73m2
References
[1] Chronic Kidney Disease (CKD) Management in General Practice (2nd edition). Kidney Health Australia,Melbourne, 2012.
Published: 01-Jul-2016 Valid until: 17-Nov-2017 Printed on: 20-Dec-2017 © Map of Medicine Ltd
This care map was published by Frankston MorningtonPsula. A printed version of this document is not controlled so may not be up-to-date
with the latest clinical information.
Page 7 of 13
Chronic kidney disease management − primary care
A-Z Frankston-Mornington Peninsula local pathways > Chronic Kidney Disease > Chronic kidney disease
• People with CKD have a 20 times greater risk of dying from cardiovascular events than requiring dialysis or transplantation
• People with moderate or severe CKD (defined as persistently having a urine ACR >25 mg/mmol (males) or >35 mg/mmol
2
(females) or eGFR <45mL/min/1.73m are considered to be at the highest risk of a cardiovascular event and do not need to be
assessed by the cardiovascular risk tool.
• For these groups, identifying all cardiovascular risk factors present will enable intensive management by lifestyle interventions
(for all patients) and pharmacological interventions (where indicated).
References
[1] Chronic Kidney Disease (CKD) Management in General Practice (2nd edition). Kidney Health Australia,Melbourne, 2012.
24 Preemptive Transplantation
Quick info:
Preemptive Transplantation
Preemptive transplantation means receiving a kidney transplant from a live donor prior to initiation of dialysis. Preemptive
transplantation is associated with:
• reduced risk of death
• longevity of functioning of the transplanted kidney
• psychosocial benefits
• economic benefits
A preemptive transplant can only be performed when the individual’s kidney function has deteriorated to a level that justifies the risks
2
and complications of transplantation (eGFR usually 8-15 mL/min/1.73m ), but before dialysis is needed.
References
[1] Chronic Kidney Disease (CKD) Management in General Practice (2nd edition). Kidney Health Australia,Melbourne, 2012.
Commonly prescribed drugs that may need to be reduced in dose or ceased in CKD
• Antivirals
• Benzodiazepines
• Colchicine
• Dabigatran
• Digoxin
• Exenatide
• Fenofibrate
• Gabapentin
• Insulin
• Lithium
• Metformin*
• Opioid analgesics
• Saxagliptin
• Sitagliptin
• Sotalol
• Spironolactone
Published: 01-Jul-2016 Valid until: 17-Nov-2017 Printed on: 20-Dec-2017 © Map of Medicine Ltd
This care map was published by Frankston MorningtonPsula. A printed version of this document is not controlled so may not be up-to-date
with the latest clinical information.
Page 8 of 13
Chronic kidney disease management − primary care
A-Z Frankston-Mornington Peninsula local pathways > Chronic Kidney Disease > Chronic kidney disease
• Sulphonylureas (all)
• Vildagliptin
2
*use with caution if GFR 30-60 mL/min/1.73m
2
; not recommended if GFR < 30 mL/min/1.73m
Commonly prescribed drugs that can adversely affect kidney function in CKD
• NSAIDs and COX-2 inhibitors
• Beware the ‘triple whammy’ of NSAID/COX-2 inhibitor, ACE inhibitor and diuretic
• (low dose aspirin is okay)
• Radiographic contrast agents
• Aminoglycosides
• Lithium
• Calcineurin inhibitors
Glycaemic control
For people with diabetes, blood glucose control significantly reduces the risk of developing CKD, and in those with CKD reduces the
rate of progression.
References
[1] Chronic Kidney Disease (CKD) Management in General Practice (2nd edition). Kidney Health Australia,Melbourne, 2012.
Published: 01-Jul-2016 Valid until: 17-Nov-2017 Printed on: 20-Dec-2017 © Map of Medicine Ltd
This care map was published by Frankston MorningtonPsula. A printed version of this document is not controlled so may not be up-to-date
with the latest clinical information.
Page 9 of 13
Chronic kidney disease management − primary care
A-Z Frankston-Mornington Peninsula local pathways > Chronic Kidney Disease > Chronic kidney disease
• Hypertension may be difficult to control and multiple (3 - 4) medications are frequently required
ACE inhibitors and ARBs can cause a reversible reduction in GFR when treatment is initiated. If the reduction is less than 25% and
stabilises within two months of starting therapy, the ACE inhibitor or ARB should be continued.
If the reduction in GFR exceeds 25% below the baseline value, the ACE inhibitor or ARB should be ceased and consideration given
to referral to a Nephrologist for bilateral renal artery stenosis
References
[1] Chronic Kidney Disease (CKD) Management in General Practice (2nd edition). Kidney Health Australia,Melbourne, 2012.
28 Anaemia management
Quick info:
Anaemia of CKD is related to both:
• reduced erythropoietin production by the kidney
• resistance to the action of erythropoietin
2.
Anaemia related to CKD usually occurs at GFRs of <60 mL/min/1.73m
The prevalence of anaemia increases markedly with decreasing GFR.
Management
• Other forms of anaemia should be considered and excluded.
• B12 and folate levels should be checked and corrected if deficient.
• Iron deficiency is a common cause of anaemia in people with CKD.
• If iron deficiency is identified any other cause should be excluded (e.g., blood loss).
• In people with CKD treated with erythropoiesis stimulating agents (ESA or EPO) iron supplementation is typically required. This
can be given either as oral iron or not infrequently as intravenous supplementation (more information on IV supplementation
such as Ferinject is available from NPS). Intramuscular iron is not recommended.
References
[1] Chronic Kidney Disease (CKD) Management in General Practice (2nd edition). Kidney Health Australia,Melbourne, 2012.
References:
1. Kidney Health Australia. Chronic Kidney Disease Management in General Practice. 2nd Edition. 2012
2.The Gold Standard Framework (GSF). Prognostic Indicator Guidance. Walsall: GSF; 2011.
30 BP lowering agents
Published: 01-Jul-2016 Valid until: 17-Nov-2017 Printed on: 20-Dec-2017 © Map of Medicine Ltd
This care map was published by Frankston MorningtonPsula. A printed version of this document is not controlled so may not be up-to-date
with the latest clinical information.
Page 10 of 13
Chronic kidney disease management − primary care
A-Z Frankston-Mornington Peninsula local pathways > Chronic Kidney Disease > Chronic kidney disease
Quick info:
ACEI and ARB
ACEI or ARB can be safely prescribed in patients with any stage of kidney disease, bearing in mind the following points [1]:
There is a significant risk of hyperkalaemia
• Stop the ACEI or ARB if potassium concentration is more than 6 mmol/L and does not respond to dose reduction, diuretic
therapy and dietary potassium restriction.
In patients with haemodynamically significant renal artery stenosis, ACEI and ARB can cause further impairment of glomerular
perfusion in the affected kidney, and precipitate acute deterioration in kidney function.
When commencing ACEI it is advisable to check renal function in 2 weeks then test monthly tests for 3 months, then test 3-6
monthly (KW).
• Monitor serum levels of creatinine and potassium closely.
• If the acute decrease in estimated glomerular filtration rate (eGFR) is less than 25% below the baseline and stabilises within 2
months of starting therapy, the ACEI or ARB may be continued.
• If the decrease in eGFR is greater than 25% below the baseline, stop the ACEI or ARB and refer the patient for investigation of
possible bilateral renal artery stenosis.
Take particular care in a patient with kidney disease treated with both an ACEI or ARB and a diuretic.
• Do not add a nonsteroidal anti-inflammatory drug (including selective cyclo-oxygenase-2 [COX-2] inhibitors) to this combination
—the 'triple whammy'—as this can cause acute kidney failure.
Most ACEI are renally excreted, and therefore lower doses are likely to be needed to control hypertension. Most ARB are
predominantly excreted by the liver, so no dose adjustment is necessary.
ACEI therapy may interfere with the actions of erythropoietin.
Loop dieuretics
At significantly reduced levels of kidney function (eGFR less than 50 mL/min), loop diuretics are used, because thiazide diuretics are
no longer effective.
The dose should be adjusted according to the level of kidney function, commencing with frusemide 40 mg/day or bumetanide 1
mg/day, increasing gradually to a maximum frusemide dose of 500 mg/day or bumetanide 10 mg/day. High doses carry a risk of
ototoxicity and should only be considered in consultation with a nephrologist.
Beta blockers
Some beta blockers (eg atenolol) are renally excreted, and dosage adjustment may be necessary in kidney disease.
• They can have deleterious effects on lipids and potassium.
• They are associated with erectile dysfunction in some patients, which may limit their use, as the incidence of impotence
increases in kidney failure.
Alpha blockers
Alpha blockers can cause unacceptable orthostatic hypotension on initial dosage and when the dose is increased.
• In the longer term, increasingly higher doses may be needed to achieve the same effect, which limits their usefulness.
However, occasionally they may be useful adjunctive therapy.
Minoxidil
The potent vasodilator minoxidil can be very effective in some patients with kidney disease and severe hypertension, but the
associated sodium retention and tachycardia limit its use.
Reference
1. Cardiovascular [revised 2012]. In: eTG complete [Internet]. Melbourne: Therapeutic Guidelines Limited; 2014 Nov.
Published: 01-Jul-2016 Valid until: 17-Nov-2017 Printed on: 20-Dec-2017 © Map of Medicine Ltd
This care map was published by Frankston MorningtonPsula. A printed version of this document is not controlled so may not be up-to-date
with the latest clinical information.
Page 11 of 13
Chronic kidney disease management − primary care
A-Z Frankston-Mornington Peninsula local pathways > Chronic Kidney Disease > Chronic kidney disease
32 REFERRAL Nephrologists
Quick info:
Referral criteria for nephrologist may include [1]:
• glomerular haematuria with macroalbuminuria
2
• eGFR <30 mL/min/1.73m
• persistent significant albuminuria (UACR ≥30 mg/mmol)
2 2
• consistent decline in eGFR from a baseline of <60 mL/min/1.73m (a decline >5 mL/min/1.73m over a 6-month period which is
confirmed on at least three separate readings)
• CKD and hypertension that is hard to get to target despite at least three antihypertensive agents.
The Department of Nephrology provides acute care to patients admitted with kidney diseases.
The range of services include acute dialysis for stable and unstable ICU/CCU patients, haemodialysis, peritoneal dialysis,
hypertension management, general renal diagnosis and management, urgent and elective kidney biopsies services. The Department
also provides a range of clinics for Haemodialysis, Peritoneal Dialysis, Pre-Dialysis education and end of life care services for patient
with kidney diseases.
Private nephrologists
Nephrologist listings from National Health Service Directory
Published: 01-Jul-2016 Valid until: 17-Nov-2017 Printed on: 20-Dec-2017 © Map of Medicine Ltd
This care map was published by Frankston MorningtonPsula. A printed version of this document is not controlled so may not be up-to-date
with the latest clinical information.
Page 12 of 13
Chronic kidney disease management − primary care
A-Z Frankston-Mornington Peninsula local pathways > Chronic Kidney Disease > Chronic kidney disease
• Dr Robert Flanc
• Dr Vinod Venkataraman
Details of relevant service providers are listed as a service for clinicians. Listing in this pathway is not an endorsement of the
provider. If any relevant providers have been missed or if information is incorrect, please use the feedback button on the bottom right
of the page to alert us.
References
[1] Chronic Kidney Disease (CKD) Management in General Practice (2nd edition). Kidney Health Australia,Melbourne, 2012.
Published: 01-Jul-2016 Valid until: 17-Nov-2017 Printed on: 20-Dec-2017 © Map of Medicine Ltd
This care map was published by Frankston MorningtonPsula. A printed version of this document is not controlled so may not be up-to-date
with the latest clinical information.
Page 13 of 13
Chronic Kidney Disease
Medicine/Nephrology
Provenance certificate
Contents
Overview
Editorial methodology
Contributors
Disclaimers
Overview
This document describes the provenance of the Peninsula Pathways, Chronic Kidney Disease care
map (pathway).
The Peninsula Pathways Program aims to improve the continuity of patient care between primary,
community and hospital care settings in the Frankston-Mornington Peninsula region. Work groups
comprising of experienced health professionals (GPs, specialists, nurses, allied health professionals)
were established to review and localise pathways.
The objective of this pathway is to improve outcomes for patients with chronic kidney disease.
Map of Medicine (MoM). Chronic Kidney Disease. Frankston-Mornington Peninsula Medicare Local
View. Melbourne: Map of Medicine; 2015.
Editorial methodology
This pathway is currently the first version localised to Frankston Mornington Peninsula.
This pathway has been developed according to the Map of Medicine editorial methodology, using
the evidence and expert advice of the international heart failure pathway as a starting point. The
content of this care map was further developed with reference to Kidney Health Australia guidelines
and other current evidence-based guidelines and practice-based knowledge provided by local
practitioners with front-line clinical experience (see contributors section of this document).
Contributors
The following were clinical contributors to the Chronic Kidney Disease pathway:
Editor
• Nick Jones | Service Integration Manager, Frankston Mornington Peninsula Medicare Local
The following were contributors through the GP review committee and wider consultation process:
Disclaimer
It is not the function of the Pathways Program, Frankston-Mornington Peninsula Medicare Local to
substitute for the role of the clinician, but to support the clinician in enabling access to know-how
and knowledge. Users of the Map of Medicine are therefore urged to use their own professional
judgement to ensure that the patient receives the best possible care. Whilst reasonable efforts have
been made to ensure the accuracy of the information on this online clinical knowledge resource, we
cannot guarantee its correctness and completeness. The information on the Map of Medicine is
subject to change and we cannot guarantee that it is up-to-date