Chronic Kidney Disease Pathway Document Description Presented ...

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High Risk Groups Renal function should be measured and recorded annually for all patients who fall into a high risk group. This is measured by Estimated Glomerular Filtration Rate (eGFR). Measurement of eGFR is available from the pathology department at Dudley Group of Hospitals. It accompanies the report following any request for Urea and Electrolytes (U+E), being calculated from the serum creatinine assay. Patients in the high risk groups are considered to be at a higher than normal risk of developing renal impairment due to co-morbities and/or medical history. Ethnicity also increases risk with black and minority ethnic (BME) groups in the U.K having up to 4 times greater risk of developing CKD. http://www.britishrenal.org/conferences/brs2007/posters/CKD%20General-48.doc The high risk groups fall into 3 main categories, morbidity, drug related and urinary. Morbidity: • Patients with Vascular disease o Coronary Heart disease o Stroke o Peripheral Vascular disease • Heart Failure • Hypertension • Diabetes • Multi-system diseases which involve the kidney, e.g. systemic lupus erythematosus, rheumatoid arthritis. • A first-degree relative with CKD stage 5. Drug related: • Patients on ACE inhibitors or angiotensin receptor blockers (ARBs) • Patients on NSAIDs, including COX II • Patients on diuretics • Patients on lithium carbonate • Mesalazine and other 5-aminosalicylic drugs • Calcineurin inhibitors (cyclosporin, tacrolimus) Urinary: • Recurrent Urinary Tract Infections • Bladder outflow obstruction • Recurrent kidney stones (>1/year) or predisposing condition, e.g. primary hyperoxaluria • Neurogenic bladder • Past surgical urinary diversion • Polycystic kidney disease • Reflux nephropathy • Biopsy proven chronic glomerulonephritis • Persistent proteinuria • Urologically unexplained persistent haematuria 10
Kidney function deteriorates naturally with age. However the conditions above may cause the kidneys to deteriorate more rapidly. Careful management of progressing factors (see pathway) could ensure a normal or close to normal/expected pattern of deterioration. Kidney function by eGFR measurement should be monitored annually in the high risk groups identified above. Frequency of monitoring of Kidney function in CKD is indicated by the table below. Frequency of Monitoring of Kidney Function in Established CKD K/DOQI eGFR Frequency Stage mls/min 1 > 90 Annually 2 60 - 89 Annually 3 30 - 59 Annually (6 monthly if newly diagnosed or progressive**) 4 15 - 29 6 monthly (3 monthly if newly diagnosed or progressive**) 5 < 15 3 monthly Stable kidney function is defined as a change of < 2mls/min in 6 months ** Progressive kidney function is defined as a change of > 2mls/min in 6 months Any patient assessed with a progressive condition should receive assessment of progressing factors and discussion/referral to nephrology services. Stage 3 Classification The UK Consensus Conference on early CKD has recommended that the Kidney Disease Outcomes Quality Initiative (KDOQI) classification should be modified by dividing CKD stage 3 into CKD 3A and 3B and that a suffix “p” should be used for all stages to denote patients with urine protein to creatinine ratio >100mg/mmol, who are at increased risk for progression and/or the development of cardiovascular disease e.g. CKD stages 2p, 3Bp. CKD stage 3 is sub-classified into 2 groups, 3A and 3B. Stage eGFR Progression to ESRD 3A 45 - 59 Lower risk 3B 44 - 30 Higher risk 11
Page 1 and 2: Chronic Kidney Disease Pathway Docu
Page 3 and 4: Pathway for the Identification and
Page 5 and 6: Contents Introduction …………
Page 7 and 8: Introduction Chronic kidney disease
Page 9: CKD Pathway D I A G N O S I S Ensur
Page 13 and 14: Joint Speciality Committee - Royal
Page 15 and 16: Acute Renal Failure Acute Renal Fai
Page 17 and 18: Next Steps Any patient suspected to
Page 19 and 20: Return to overview CKD Stages CKD S
Page 21 and 22: Practice Action Plan Compiling a Ch
Page 23 and 24: Action Rationale Responsible Run a
Page 25 and 26: eGFR
Page 27 and 28: CKD Stages CKD Stage Description Re
Page 29 and 30: References Joint Speciality Committ
Page 31 and 32: Cardiovascular Risk All patients wi
Page 33 and 34: Hypertension Blood pressure should
Page 35 and 36: Further information on the pharmaco
Page 37 and 38: Irbesartan* Valsartan Losartan* *Sp
Page 39 and 40: • Diuretics • Lithium carbonate
Page 41 and 42: Recommendation: Therefore consider
Page 43 and 44: Lower levels of proteinuria should
Page 45 and 46: Glycaemic Control CKD and Diabetes
Page 47 and 48: References Audit Commission (2002)
Page 49 and 50: Influenza and Pneumococcal Vaccine
Page 51 and 52: Stage 3 Management at stage 3 shoul
Page 53 and 54: If all other causes for the anaemia
Page 55 and 56: Clinic inclusion criteria: Patients
Page 57 and 58: Where vitamin D supplementation is
Page 59 and 60: Stage 5 Patients identified at CKD
Page 61 and 62:
Information to include with referra
Page 63 and 64:
Appendix 1 The Dudley Group of Hosp
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