Chronic Kidney Disease Pathway Document Description Presented ...

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Referral Criteria for Referral to Specialist Nephrology Services According to eGFR eGFR mls.min Indication < 15 Stage 5 15 – 29 Stage 4 Urgent referral (exceptions) Referral to “one stop” clinic for assessment, investigations and shared management plan 30 – 59 Stage 3 Routine referral/advice indications: • Where condition is not shown to be stable ie. progressive deterioration in kidney function • Microscopic haematuria • PCR >45 mg/mmol (ACR > 70mg/mmol) • Unexplained anaemia (Hb < 11) • Continuing abnormal potassium, calcium or phosphate levels despite advice in this pathway • Suspected systemic illness, e.g. SLE • Uncontrolled hypertension (>150/90 on 3 agents) > 60 Stage 1 and 2 Indications irrespective of eGFR Referral not required unless other problems present (see below) Immediate referral: • Accelerated hypertension • Hyperkalaemia (K > 7.0 mmol/l) Urgent referral • Nephrotic syndrome (proteinuria, oedema and low serum albumin) Routine referral • Dipstick proteinuria present and PCR >100 mg/mmol • Dipstick proteinuria and microscopic haematuria present • Macroscopic haematuria with negative urological testing • People with, or suspected of having, rare or genetic causes of CKD • Suspected renal artery stenosis. 60
Information to include with referral • General medical history and details of co-morbidities • Urinary symptoms • Medication • Current blood pressure reading and all blood pressure readings over the last 2-3 years or back to normal levels, in date order, in graph form if available. If incomplete, send as much information as available • Current eGFR and serum creatinine levels and all levels over the last 2-3 years or back to normal levels, in date order, or graph if available. If incomplete, send as much information as available. • Examination findings, e.g. oedema, palpable bladder • Urine dipstick results for blood and protein • PCR if proteinuria present. If no proteinuria present, microalbumin for all patients, plus ACR for diabetic patients. • U and E, FBC, albumin, calcium, phosphate, cholesterol. HbA1c if diabetic. • Results of any renal ultrasound scan if available. Once a referral has been made and a plan jointly agreed, consider routine follow-up in primary care rather than in the specialist clinic. Specify criteria for future referral / re-referral and when to seek advice. Renal Ultrasound Renal ultrasound is indicated in: • progressive CKD • visible or persistent invisible haematuria • symptoms of urinary tract obstruction • family history of polycystic kidney disease and are aged over 20 • stage 4 or 5 CKD • nephrologist recommendation for renal biopsy. Advise people with a family history of inherited kidney disease about the implications of an abnormal result before arranging the scan. Return to overview 61
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 and 10: CKD Pathway D I A G N O S I S Ensur
Page 11 and 12: Kidney function deteriorates natura
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: Stage 5 Patients identified at CKD
Page 63 and 64: Appendix 1 The Dudley Group of Hosp
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