Chronic Kidney Disease Pathway Document Description Presented ...

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Abbreviations ACE ARB ARF BP CAPD CKD DGoH DIP eGFR ERF ESA FBC GI GMS Hb KDOQI LIT MDRD NSAID OTC QMAS QOF RHH U+E UTI Angiotensin Converting Enzyme Angiotensin Receptor Blocker Acute Renal Failure Blood Pressure Continuous Ambulatory Peritoneal Dialysis Chronic Kidney Disease Dudley Group of Hospitals Diabetes Improvement Partnership estimated Glomerular Filtration Rate Established Renal Failure Erythropoietin Stimulating Agent Full Blood Count Gastrointestinal General Medical Services Haemoglobin Kidney Disease Outcomes Quality Initiative Local Implementation Team Modified Diet in Renal Disease Non- Steroidal Anti-Inflammatory Drug Over The Counter Quality Management and Analysis System Quality and Outcomes Framework Russell’s Hall Hospital Urea and Electrolytes Urinary Tract Infection Return to overview 62
Appendix 1 The Dudley Group of Hospitals NHS Trust Pathway for the Management of Calcium and Phosphate balance in Chronic Kidney Disease within Dudley Health Economy Rationale: Hyperphosphataemia (elevated serum phosphate) is recognised as an important risk factor for many adverse outcomes in dialysis patients, including vascular calcification, calciphylaxis, secondary hyperparathyroidism and mortality. Retention of phosphate occurs much earlier in the course of CKD. Serum phosphate concentration increases when eGFR falls below 30 mls/minute (CKD 4). Aim: To maintain phosphate levels between 0.9-1.5 mmol/L (1) and between 1.1 and 1.8 mmol/L in dialysis patients. Dietary Modification: Patients with CKD may need to follow a reduced phosphate diet. Phosphate rich foods include chocolate, nuts, dairy, eggs, meat and fish. This needs to be balanced carefully and so referral to a specialist dietitian is essential. If phosphate or intact PTH levels cannot be controlled within target range despite dietary phosphate restriction then prescribe a phosphate binder. Calcium containing phosphate binders 1 st Line Choice: Calcium Carbonate (Calcichew®) 1.25g (Contains 500mg elemental calcium per tablet) Dose: To be titrated starting at 1 bd up to 2 tds with meals S/E: diarrhoea, hypercalcaemia Alternatives: Adcal ® 1.5g (Contains 600mg elemental calcium per tablet) or add D3 in those at risk of Osteoporosis with CKD stages 1-3 2 nd Line Choice: Calcium Acetate (Phosex®) 1000mg Indication – hyperphosphataemia and intolerance to calcium carbonate or contraindicated. NB - contains less elemental calcium compared to calcium carbonate for the same phosphate binding capacity; this is also affected less by gastric pH. Dose: 1g tds with meals titrated according to serum phosphate levels, max 12 daily. S/E: nausea and vomiting, constipation. NB - Prescribing should be in line with an effective shared care agreement (ESCA) Calcium Acetate.doc * MONITORING Parameter Serum Phosphorous concentration Serum calcium concentration Frequency of Monitoring Every 2-4 weeks until stable levels are reached and then 1-3 months as directed by the clinician Target (KDOQI, Renal Association, recommendations for stages of CKD) CKD Stage 3/4 0.9 – 1.5 mmol/l Dialysis 1.1 – 1.8 mmol/l 1-2 monthly CKD Stage 3/4 2.1 - 2.6 mmol/l Dialysis 2.2 – 2.5 mmol/l Ca x P CKD Stage 3/4 2.6 mmols/l SEVELAMER (RENAGEL®) 800mg Indication: hyperphosphataemia as monotherapy or in combination with calcium containing phosphate binder. May also decrease total and LDL cholesterol. Dose: 1 tds with meals, titrate dose according to calcium and phosphate balance, max 5 per meal. SE’s/CI: CI in hypersensitivity, hypophosphataemia, bowel obstruction, young children, gastroparesis, swallowing disorders. NB – Prescribing should be in line with an ESCA Sevelamer.doc OR LANTHANUM (FOSRENOL®) Indication: hyperphosphataemia NB – May be beneficial in those who are intolerant to sevelamer or where it is desirable to reduce the pill burden. Dose: 500mg, 750mg or 1000mg with meals titrated to 1500mg or 3000mg daily. S/E’s: Abdominal pain, constipation, diarrhoea, nausea and vomiting. NB – Prescribing should be in line with an ESCA Lanthanum.doc PRESCRIBING COSTS:- / DRUG INFORMATION Phosphate binders Calcichew 2tds £15.67 Phosex 2tds £18.47 Sevelamer 3tds £171.86 Lanthanum 1tds 750mg £142.03 Cost of 28 days treatment (BNF 56) 63
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 and 60: Stage 5 Patients identified at CKD
Page 61: Information to include with referra
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