Chronic Kidney Disease Pathway Document Description Presented ...

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The great majority of patients starting RRT have progressed from earlier stages and most could therefore have been identified, managed and referred more appropriately at an earlier stage from primary care. Early CKD is common however and referral of all patients with early CKD would completely overwhelm existing specialist services. The great majority of patients with early CKD do not progress to end-stage renal disease (ESRD), but do have a substantially increased risk of cardiovascular morbidity and mortality. Optimal management of the risk factors for cardiovascular disease, such as hypertension and proteinuria will reduce the risk of progression from early CKD to ESRD and can be managed effectively in primary care. CKD Stages According to Established Estimated Glomerular Filtration Rate (eGFR) CKD Stage Description 1 Normal eGFR > 90 mL/min/1.73m 2 *With other evidence of chronic kidney damage present 2 Mild Impairment - 60-89 mL/min/1.73m 2 *With other evidence of chronic kidney damage present 3 Moderate Impairment - 30-59 mL/min/1.73m 2 3A 45 - 59 3B 44 - 30 4 Severe Impairment – 15-29 mL/min/1.73m 2 5 Established Renal Failure (ERF) < 15 mL/min/1.73m 2 or on dialysis *Other Evidence of Chronic Kidney Damage • Persistent microalbuninuria, proteinuria or haematuria (after exclusion of other causes) • Structural abnormalities seen on X-ray (e.g. polycystic kidney disease) • Biopsy proven chronic glomerulonephritis 8
CKD Pathway D I A G N O S I S Ensure annual assessment of people in high risk groups Introduction 1. Confirm diagnosis 2. Identify CKD stage 1 - 5 3. Enter onto practice system with appropriate read code compatible with GMS contract to form register. 4. Check register prevalence 5. Consider use of practice action plan template Suspicion of Chronic Kidney Disease (CKD) following investigation for other unrelated condition Is it Acute Renal Failure Urgent Admission M A N A G E M E N T CKD stage 1 and 2. Patient information and education Address progressing factors:- CV risk Hypertension lifestyle Initiation of ACE/ARB Drugs with high salt content Nephrotoxic/renally excreted drugs, inc. OTC medication Renal Artery Stenosis Urinalysis Diet in CKD Glycaemic control Flu/pneumo vac Hepatitis B immunisation Follow-up Stage 3 (3A 3B) As stage 1 and 2 plus: Management of anaemia ESA pathway CKD stage 4 As I, 2 and 3 plus shared care plan initiation. Refer to "One-Stop" Renal clinic Bone metabolism Pathway for the Management of Calcium and Phosphate Balance CKD stage 5 Urgent referral if clinically appropriate exceptions Annual review in primary care R E F E R R A L Criteria for referral to Specialist Nephrology services Renal Ultrasound Information to include with referral Palliative care trust protocol Prescribing /symptom control in advanced renal disease Seeking Advice from Nephrologist / Renal Dept. DGOH Contact information Frequently asked questions 9
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: Introduction Chronic kidney disease
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 and 62:
Information to include with referra
Page 63 and 64:
Appendix 1 The Dudley Group of Hosp
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