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Chronic Kidney Disease: Diagnosis and Management – Adult – Ambulatory

Chronic Kidney Disease: Diagnosis and Management – Adult – Ambulatory - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Urology and Nephrology, Related


1
Chronic Kidney Disease: Diagnosis and
Management – Adult – Ambulatory
Clinical Practice Guideline
Note: Active Table of Contents – Click to follow link
EXECUTIVE SUMMARY ........................................................................................................................................... 3
SCOPE .................................................................................................................................................................... 3
METHODOLOGY ..................................................................................................................................................... 4
DEFINITIONS .......................................................................................................................................................... 4
INTRODUCTION ..................................................................................................................................................... 4
RECOMMENDATIONS ............................................................................................................................................ 5
CARDIOVASCULAR RISK.................................................................................................................................................... 5
Hypertension Management .................................................................................................................................. 5
Lipid Management ................................................................................................................................................ 8
Anti-platelet therapy ............................................................................................................................................. 8
GLYCEMIC CONTROL ....................................................................................................................................................... 8
BONE MINERAL DISORDERS ............................................................................................................................................. 8
METABOLIC ACIDOSIS ..................................................................................................................................................... 8
ANEMIA ....................................................................................................................................................................... 9
MEDICATION AND CONTRAST PRECAUTIONS ........................................................................................................................ 9
PREVENTIVE HEALTH MEASURES/LIFESTYLE MODIFICATIONS ................................................................................................ 11
Dietary Considerations/Nutritional guidance ..................................................................................................... 11
Immunizations .................................................................................................................................................... 11
Smoking and Alcohol Use .................................................................................................................................... 11
Physical Activity .................................................................................................................................................. 11
EVALUATION OF CHRONIC KIDNEY DISEASE ....................................................................................................................... 12
Identifying progressive CKD ................................................................................................................................ 12
Laboratory tests to evaluate CKD ....................................................................................................................... 12
WHEN TO REFER TO NEPHROLOGY .................................................................................................................................. 12
CO-MANAGEMENT OF CHRONIC KIDNEY DISEASE PATIENTS.................................................................................................. 14
UW HEALTH IMPLEMENTATION ........................................................................................................................... 16
APPENDIX A. EVIDENCE GRADING SCHEMES ........................................................................................................ 17
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2


Contact for Content:
Name: Jeff Huebner, MD – Family Medicine
Phone Number: 608-265-6842
Email Address: jhuebner@uwhealth.org

Name: R. Allan Jhagroo, MD - Nephrology
Phone Number: (608) 270-5656
Email Address: rajhagroo@medicine.wisc.edu

Contact for Changes:
Name: Katherine Le, PharmD – Center for Clinical Knowledge Management
Phone Number: (608) 890-5898
Email Address: kle@uwhealth.org

Coordinating Team Members:
Deb Boushea, MD – Internal Medicine
Jason Dambach, MD – Internal Medicine
Jason Hampton, MD – Group Health Cooperative
Holly Hanson, NP – Long Term Care
Adrienne Paske, RN – Family Medicine
Ruth Denherder – Quality, Safety, Innovation
Carmen Vinje, RN – Wisconsin Dialysis
Karen Schlageter, RN – Wisconsin Dialysis
Sara Shull, PharmD, MBA – Drug Policy
Marie Pietruszka, PharmD – Pharmacy
Jen Grice, PharmD – Center for Clinical Knowledge Management
Kim Holdener, PharmD – Pharmacy

Review Individuals/Bodies:
Venkata Meduri, MD – Radiology
Scott Reeder, MD – Radiology

Committee Approvals/Dates:
Clinical Knowledge Management (CKM) Council (Last Periodic Review: MM/DD/YY)


Release Date: September 2017 | Next Review Date: June 2019














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3


Executive Summary
Guideline Overview
This guideline has been developed to help clinicians better manage their patients with chronic
kidney disease by way of goals and interventions to help delay the progression of disease and
gives considerations on way to specialty care (i.e., nephrology) may be needed.

Key Practice Recommendations
1. A target blood pressure of ≤ 140/90 mm Hg is recommended for CKD patients with no
proteinuria. For CKD patients with proteinuria (i.e., urine protein/Cr ratio >0.5 or ≥0.22
African-Americans), a blood pressure goal < 130/80 mm Hg may be considered.
2. An ACE-inhibitor or ARB is recommended as first line anti-hypertensive treatment for CKD
patients with or without diabetes.
1

3. Statin therapy is recommended with or without ezetimibe in CKD patients ≥ 50 years. For
CKD patients 18-49 years of age, statin therapy is recommended if there is high risk for
cardiovascular disease (i.e., history of coronary artery disease, diabetes, history of stroke or
10 year risk of myocardial infarction > 10%).
4. It is not recommended to initiate statin therapy in dialysis patients.
5. A daily low-dose aspirin is recommended in adults with CKD for secondary prevention of
cardiovascular disease unless the risk of bleeding outweighs the benefits.
6. A target blood HbA1c of 7% is recommended for CKD patients.
7. For patients with CKD stage 3a or worse (e.g., GFR < 60mL/min/1.73m2), it is
recommended to obtain serum calcium, phosphorus, intact parathyroid hormone, and total
25-hydroxy vitamin D at least once to establish baseline levels.
8. It is recommended that hemoglobin be measured at least annually beginning with Stage 3a
CKD (e.g., GFR <60).
9. Clinicians are advised to counsel patients on avoiding chronic NSAIDs and COX-2
inhibitors, especially over-the-counter preparations (e.g., naproxen, ibuprofen.)
10. Patients with CKD and diabetes or patients without diabetes with GFR < 30 should be
referred to a dietitian for nutritional guidance, including restricting protein intake.
11. It is recommended for Primary Care and Nephrology providers to engage patients in
discussion on topics related to the patient’s CKD disease status such as palliative care and
transplant consideration and educate patients on renal replacement planning interventions.
Scope
Disease/Condition(s): Chronic Kidney Disease (CKD)

Clinical Specialty: Internal Medicine, Nephrology, Pharmacy, Family Medicine

Intended Users: Physicians, Advanced Practice Providers, Pharmacists, Nurses

Objective(s):To assist in the initial diagnosis/evaluation and on-going management chronic
kidney disease patients not on dialysis

Target Population: Adult patients with chronic kidney disease who are not on dialysis

Interventions and Practices Considered:
• Advanced Care Planning
• Dialysis Planning
• Palliative Care Planning

Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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4


Major Outcomes Considered:
• Identification of chronic kidney disease patients
• Prevention of CKD complications
• Timely referral to Nephrology
Methodology
Methods Used to Collect/Select the Evidence:
Electronic database searches (e.g., PUBMED) were conducted by the guideline author(s) and
workgroup members to collect evidence for review. Expert opinion and clinical experience were
also considered during discussions of the evidence.

Methods Used to Formulate the Recommendations:
The workgroup members agreed to adopt recommendations developed by external
organizations and/or arrived at a consensus through discussion of the literature and expert
experience. All recommendations endorsed or developed by the guideline workgroup were
reviewed and approved by other stakeholders or committees (as appropriate).

Methods Used to Assess the Quality of the Evidence/Strength of the Recommendations:
Recommendations developed by external organizations maintained the evidence grade
assigned within the original source document and were adopted for use at UW Health.

Internally developed recommendations, or those adopted from external sources without an
assigned evidence grade, were evaluated by the guideline workgroup using an algorithm
adapted from the Grading of Recommendations Assessment, Development and Evaluation
(GRADE) methodology (see Figure 1 in Appendix A).

Rating Scheme for the Strength of the Evidence/Recommendations:
See Appendix A for the rating scheme(s) used within this document.

Recognition of Potential Health Care Disparities: It has also been noted that disparities in
CKD and ESRD incidence disproportionately affect racial/ethnic minorities and persons with low
socioeconomic status. Chronic kidney disease is more common among African-American and
Latino individuals. In addition, low socioeconomic status is associated with low estimate
glomerular filtration rate (eGFR), high albuminuria and renal failure.
2,3
Women also have a
higher overall rate of CKD however end stage renal disease (ESRD) is more common among
men.
3

Definitions
Chronic Kidney Disease is defined as either kidney damage (albuminuria, kidney biopsy
findings, or imaging abnormalities) for ≥ 3 months independent of cause or an estimated
glomerular filtration rate (GFR) < 60 mL/min/1.73m
2
.
Introduction
Chronic kidney disease (CKD) is typically defined as kidney damage ≥ 3 months or a GFR < 60
mL/min/1.73m2. The disease can be further classified by underlying cause, GFR category, and
albuminuria category with severity of disease staged and based on the patient’s estimated GFR.
Table 1 outlines the GFR categories and albuminuria categories of CKD as defined in the 2012
Kidney Disease Improving Global Outcomes (KDIGO) guideline.
4


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5


Table 1. Chronic Kidney Disease Stages by GFR and Albuminuria categories
GFR categories Albuminuria categories
Stage Kidney function GFR
(ml/min/1.73m
2
)
Stage Albuminuria
description
Range
G1 Normal or high ≥ 90 A1
Normal to mildly
increased
< 30mg/g
G2 Mildly decreased 60-89 A2
Moderately
increased
30-299 mg/g
G3a Mildly to moderately
decreased
45-59 A3
Severely
increased
≥300 mg/g
G3b Moderately to severely
decreased
30-44
G4 Severely decreased 15-29
G5 Kidney failure < 15


It is estimated that approximately 14% of the adult US population suffers from chronic kidney
disease, making it more prevalent than diabetes.
3
CKD in its early stages may be undetected
because the patient is asymptomatic. Ultimately the disease may progress to the point of the
patient requiring chronic dialysis which can be a significant medical and cost burden to the
patient. However, it is important to note that a patient with stage 3 CKD is 20 times more likely
to die of a cardiovascular event than to reach end stage renal disease.
5
Thus, it becomes
increasingly important and vital for primary care providers to work collaboratively with
nephrologists to manage these patients to prevent disease progression and mortality risk.
Recommendations
Cardiovascular Risk
Cardiovascular risk is significant in chronic kidney disease patients because most patients with
CKD are 10 times more likely to die from a cardiovascular event than end stage renal disease.
3

Moreover, two interventions known to help delaying CKD progression are blood pressure control
and the use of angiotensin-converting enzyme inhibitors(ACE-I) or angio-tensin receptor
blockers (ARB) for albuminuria and hypertension.
1

Hypertension Management
1. A target blood pressure of ≤ 140/90 mm Hg is recommended for chronic kidney disease
patients with no proteinuria.
1,4
(KDIGO 1B)
2. For CKD patients with proteinuria (i.e., urine protein/Cr ratio >0.5 or ≥0.22 African-
Americans), consider a blood pressure goal < 130/80 mm Hg. (UW Health Low quality of
evidence, weak/conditional recommendation)
3. An ACE-inhibitor or ARB is recommended as first line treatment for hypertension in CKD
patients with or without diabetes.
1
(UW Health Moderate quality of evidence, weak/conditional
recommendation) ACE-inhibitors or ARBs are especially recommended for patients with
proteinuria and clinicians should consider titrating to the maximum tolerable dose before
addition of another hypertensive agent.
6
Refer to Figure 1 for additional guidance on
initiating an ACE-I or ARB. (UW Health Low quality of evidence, strong recommendation)
a. In black patients, there is good evidence for renal protective effects for ACE
inhibitors.
b. In general, concurrent use of an ACE inhibitor and ARB for hypertension is not
recommended, regardless of whether or not the patient has diabetes too. (UW
Health Low quality of evidence, strong recommendation) Studies how shown
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6


increased complications such as acute kidney injury and no mortality benefits
with combination versus single agent therapy.
c. One study demonstrated stopping ACE inhibitor or ARB in advanced stage 4
CKD (mean GFR 16 mL/min/1.73m
2
) associated with improved GFR and delayed
onset of dialysis.
d. Upon initiating an ACE inhibitor or ARB, it is recommended to consider checking
serum creatinine and potassium in 7-10 days. If creatinine or potassium
increases, renal function may need to be re-checked and medication titrated.
(UW Health Low quality of evidence, strong recommendation) Refer to Figure 1 for
additional information.
4. In patients with proteinuria, it is recommended to avoid dihydropyridine calcium channel
blockers (e.g., amlodipine, nifedipine) without an ACE inhibitor or ARB, as these
medications can worsen proteinuria.
5
(UW Health Low quality of evidence, weak/conditional
recommendation) Nondihydropyridine calcium channel blockers (e.g., diltiazem,
verapamil) may be used though to help reduce proteinuria. Table 2 suggests first and
second line anti-hypertensive agents for CKD patients and other considerations when
selecting a medication.
5. Diuretic therapy may be necessary to help manage fluid volume expansion and help with
blood pressure control in CKD.
1,7

a. Thiazides may be used for patients with stages G1-3b chronic kidney disease as
they lose their effectiveness in stage 4 or 5 CKD (GFR <30 mL/min/1.73m
2
)
patients.
1,7

b. Loop diuretic such as furosemide, may be considered as second-line option if
thiazide does not achieve control goal. Most patients with stage G4 CKD will
require a loop diuretic and they are especially effective if there is concomitant
edema.
1,7

c. It is recommended if using furosemide to dose as twice daily for effective
diuresis.
1,7
(UW Health Low quality of evidence, weak/conditional recommendation)


Table 2. Anti-hypertensive agents selection in CKD patients
6

1
st
line ACE inhibitor or ARB

Titrate to highest tolerable dose
2
nd
line/3
rd
line Diuretic/Calcium channel blocker*

* For patients with proteinuria, consider non-dihydropyridine calcium
channel blocker.
For patients who are fluid overloaded, consider diuretic.
4
th
line Add alpha blocker or beta blocker

For additional information on managing hypertension, refer to the Diagnosis and Management
of Hypertension UW Health clinical practice guideline.




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7


Figure 1. Initiating ACE inhibitor or ARB in CKD patient
6





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8


Lipid Management
1. Statin therapy is recommended with or without ezetimibe in CKD patients ≥ 50 years.
7

(UW Health Low quality of evidence, weak/conditional recommendation)
2. Statin therapy is recommended with or without ezetimibe in CKD patients ages 18-49
years with high cardiovascular disease risk (i.e., history of coronary artery disease,
diabetes, history of stroke or 10 year risk of myocardial infarction > 10%).
1,7
(UW Health
High quality of evidence, strong recommendation)
3. It is not recommended to initiate statin therapy in dialysis patients.
7
(UW Health Low
quality of evidence, strong recommendation)
4. It is not recommended to use statins concurrently with fibrates due to an increased risk
of myopathy and rhabdomyolysis.
7
(UW Health Moderate quality of evidence,
weak/conditional recommendation)
5. If hypertriglyceridemia is present, fish oil may be considered in addition to statin therapy
or statin-ezetimibe therapy.
7

Anti-platelet therapy
1. A daily low-dose aspirin is recommended in adults with CKD for secondary prevention of
cardiovascular disease unless the risk of bleeding outweighs the benefits.
1,4
(KDIGO 2B)
Glycemic control
It is well known that uncontrolled diabetes can eventually lead to kidney damage, and thus
chronic kidney disease. One intervention to reduce CKD progression is diabetes control. In
addition to cardiovascular risk reduction, glycemic control can help reduce progression of
albuminuria. A target blood HbA1c of 7% is recommended, with a higher target for patients with
a limited life expectancy or an elevated risk of hypoglycemia.
1,4
(KDIGO 1C)

For additional guidance on managing a patient’s diabetes, refer to the Standards in Medical
Care - Diabetes- UW Health clinical practice guideline.
Bone Mineral Disorders
Chronic kidney disease-mineral and bone disorder is a complex, multifactorial process. The
onset of complications (e.g., secondary hyperparathyroidism, hypocalcemia,
hyperphosphatemia, decreased vitamin D and vascular calcification) typically begin in stage 3b
CKD.
1,3

1. For patients with CKD stage 3a or worse (e.g, GFR < 60mL/min/1.73m
2
), it is
recommended to obtain serum calcium, phosphorus, intact parathyroid hormone, and
total 25-hydroxy vitamin D at least once to establish baseline levels.
1,4,7
(KDIGO 1C)
2. It is recommended to replace vitamin D if patient is deficient.
1,5
(UW Health Low quality of
evidence, weak/conditional recommendation)
3. Consider e-consult/referral to Nephrology for patients with an elevated phosphorus or
parathyroid hormone level prior to initiating medical therapy.
5
(UW Health Low quality of
evidence, weak/conditional recommendation)
Metabolic Acidosis
Metabolic acidosis can occur when the kidneys no longer maintains the acid-balance well (e.g.,
keeping blood from being too acidic by reabsorbing bicarbonate filtered in urine by glomerulus
and excreting daily acid load.) Metabolic acidosis often develops in advanced stages of CKD,
when GFR <20mL/min/1.73m
2
.
5
A bicarbonate level ≤ 22 mmol/L has been associated with risk
of worsening renal function.
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1. It is recommended that if a patient’s bicarbonate level < 22 mmol/L, the patient is
prescribed sodium bicarbonate (650mg) 3 times daily.
1
(KIDGO 2B)
a. Sodium bicarbonate 650mg corresponds to 23 mEq daily of sodium and
bicarbonate.
b. Sodium citrate (30 mL daily) may be used as an alternative, corresponding to 3-
mEq of sodium and bicarbonate a day.
2. If after sodium bicarbonate supplementation a patient’s level is not ≥ 22 mmol/L, it is
recommended to consider a nephrology referral.
1
(UW Health Low quality of evidence,
weak/conditional recommendation)
Anemia
Anemia is a common complication of chronic kidney disease. It is twice as common in CKD
patients versus patients without CKD and the prevalence increases as a patient’s disease
progresses (8.4% at stage 1 to 53.4% at stage 5.)
7
A diagnosis of anemia occurs when
hemoglobin (Hgb) < 13g/dL in adult males and < 12 g/dL in adult females.
3,7

1. It is recommended that hemoglobin be measured at least annually beginning with stage
G3a CKD because erythropoietin production decreases with low GFR.
1
(UW Health Low
quality of evidence, weak/conditional recommendation)
2. For patients with stage 4 to 5 CKD, anemia screening may be considered every 6
months.
3
(UW Health Low quality of evidence, weak/conditional recommendation)

For guidance on managing anemia in a CKD patient, refer to the Anemia Management in
Chronic Kidney Disease - UW Health clinical practice guideline
Medication and Contrast Precautions

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and COX-2 Inhibitors
It is strongly recommended that clinicians counsel chronic kidney disease patients on avoiding
chronic NSAID use, especially over-the-counter preparations (i.e., ibuprofen, naproxen) and
Cox-2 inhibitors (e.g., celecoxib.) Patients should also be educated on the difference between
chronic NSAIDs use and taking a daily low-dose aspirin for secondary prevention of
cardiovascular disease.
8
(UW Health Low quality of evidence, strong recommendation)

Oral Sodium Phosphate
Oral sodium phosphate-containing preparations in bowel preparation can put CKD patients at
risk for acute phosphate nephropathy. Patients with a GFR < 60mL/min/1.73m
2
should avoid
oral phosphate bowel pill preparations.
1,4,8
(KDIGO 1A)

Gadolinium-Containing Contrast
In patients with severe CKD, some gadolinium-based contrast agents (GBCA) may pose a risk
for nephrogenic systemic fibrosis (NSF). According to the American College of Radiology
(ACR) Manual on Contrast Media, the likelihood of a patient developing NSF depends on the
formulation of GBCA. Gadodiamide is a Group I GBCA associated with a higher risk of NSF
and is no longer on formulary at UW Health. The only agents on formulary are Group II GBCA
agents (i.e., gadobenate dimeglumine, gadoterate acid) and a Group III agent (i.e., gadoxetate
disodium). Per the ACR Manual on Contrast Media, “the risk of NSF among patients exposed
to standard or lower than standard doses of group II GBCAs is sufficiently low or possibly
nonexistent” while Group III agents have limited data regarding NSF risk.
9


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10


Therefore, the following considerations are recommended when using gadolinium-containing
contrast agents for chronic kidney disease patients:
1. If gadolinium is medically necessary in patients with GFR < 30 mL/min/1.73m
2
, it is
recommended to use an agent associated with a lower risk of NSF and use the lowest
dose possible of contrast. (UW Health High quality evidence, strong recommendation)
2. Dialysis following gadolinium-administration is not recommended for patients who are
not on dialysis already. (UW Health Low quality evidence, strong recommendation)
3. For CKD patients who are on dialysis, it is recommended to attempt to coordinate the
patient’s magnetic resonance imaging (MRI) exam with his/her dialysis schedule
however coordination of MRI should not delay the MRI exam in a clinically meaningful
way. (UW Health Low quality evidence, weak/conditional recommendation)
4. If there is provider concern regarding gadolinium use with a CKD patient, a risk-benefit
analysis discussion is recommended between the ordering provider and the Radiology
service. (UW Health Low quality evidence, strong recommendation)

Dose adjustment based on renal function
It is recommended that providers consult a drug information reference such as Lexicomp or
Micromedex when prescribing medications for a CKD patient to determine if renal dose
adjustment is necessary.
4
(KDIGO 1A) Table 3 lists some examples of commonly prescribed
drug classes and drugs that may require renal dose adjustment or should be used with caution
in CKD patients.

Table 3. Select drugs that may require monitoring/dose adjustment in CKD patients
1,3,8

Anti-hypertensives/
cardiac medications
• Beta blockers
• Digoxin
• Thiazides
Analgesics
• NSAIDs
• Opioids
• Tramadol
Antimicrobials
• Beta-lactams
• Macrolides
• Fluoroquinolones
• Tetracyclines
• Anti-fungals
• Anti-virals
• Trimethoprim and
Trimethoprim/sulfamethoxazole
Anti-coagulants
• Low-molecular weight heparins
• Warfarin
• Direct oral anticoagulants
Hypoglycemics
• Sulfonylureas
• Insulin
• Metformin
Lipid-lowering
• Statins
• Fenofibrate
Gout-related
• Allopurinol
• Colchicine
Miscellaneous
• Lithium
• Bisphosphonates
• Gabapentin
• Ranitidine
• Metoclopramide
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11


Preventive Health Measures/Lifestyle Modifications
Dietary Considerations/Nutritional guidance
1. It is recommended that CKD patients receive dietary advice from a dietitian in the
context of an education program, tailored to severity of the kidney disease and provides
education on salt, phosphate, potassium and protein intake.
8
(UW Health Low quality of
evidence, weak/conditional recommendation)
2. Patients should be counseled to restrict sodium intake to < 2000 mg/day.
1,4
(KDIGO 1C)
3. It is recommended that patients limit saturated and trans fat (e.g., “partially
hydrogenated oils”) and substitute instead with monounsaturated and polyunsaturated
fats (e.g., nuts, seed oils.)
10
(UW Health Low quality of evidence, weak/conditional
recommendation)
4. For patients with diabetes OR patients without diabetes with GFR <30, it is
recommended for the patient to be referred to a dietitian for nutritional guidance, such as
restricting protein intake. (UW Health Low quality of evidence, weak/conditional
recommendation)
Immunizations
It is recommended that patients with chronic kidney disease receive an annual influenza
vaccine, unless contraindicated.
11
(UW Health Moderate quality of evidence, weak/conditional
recommendation)

The polyvalent pneumococcal vaccine (PPSV-23) is recommended for adults ≥ 19 years with
severe kidney disease (GFR <30 ml/min/1.73
2
) and at high risk of pneumococcal infection (e.g.,
diabetes, nephrotic syndrome, receiving immunosuppression), unless contraindicated. Offer to
revaccinate within 5 years.
11
(UW Health Moderate quality of evidence, weak/conditional
recommendation)

It is recommended for patients with GFR <30 ml/min/1.73
2
to receive the Hepatitis B vaccination
series and to confirm response with appropriate serological testing thereafter.
11
(UW Health Low
quality of evidence, weak/conditional recommendation)
Smoking and Alcohol Use
Chronic kidney disease patients should be advised to stop smoking and limit alcohol.
4,8
(KDIGO
1D)

For guidance on tobacco cessation interventions and alcohol interventions for CKD patients
refer to the UW Health Assessment of Tobacco Use or Secondhand Exposure and Interventions
for Tobacco Cessation and UW Health Alcohol Assessment and Intervention clinical practice
guidelines.
Physical Activity
Clinicians should encourage patients to exercise and to follow general physical activity
guidelines if possible. The recommended exercise duration for adults is 150 minutes a week of
moderate-intensity.
4,8,12
(KDIGO 1D)
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12


Evaluation of Chronic Kidney Disease
Identifying progressive CKD
It is recommended to obtain a minimum of three eGFR estimations over a period of 90 days or
more. Progressive chronic kidney disease is considered a decline in eGFR of >5ml/min/1.73m
2

within 1 year or >10 ml/min/1.73m
2
within 5 years.
13

Laboratory tests to evaluate CKD
Table 4 lists suggested labs and interventions to conduct when a patient is initially diagnosed
with chronic kidney disease and frequency of test depending on the patient’s disease status.

Table 4. Laboratory tests to evaluate chronic kidney disease in patients upon diagnosis
and for follow-up
3

Evaluation/Monitoring Frequency
Test/Intervention Rationale/
Indication
CKD 3a
(GFR 45-59)
CKD 3b
(GFR 30-44)
CKD 4
(GFR 15-29)
CKD 5
(GFR <15)
Basic metabolic panel Prognosis,
hyperkalemia,
metabolic bone
disease
Per
Physician
discretion
Annually
(unless
changes to
medication
or condition
dictate
otherwise)
Every 3-4
months
Per Nephrologist
recommendation
Protein/creatinine ratio Prognosis
Urinalysis with
Microscopy (UA)
Prognosis
Hemoglobin/hematocrit Prognosis,
anemia
Lipids CV risk
stratification
Ultrasound of kidneys Prognosis
PTH, vitamin D*

*Test if GFR < 45
upon diagnosis
Metabolic bone
disease


Phosphate**

**Test if GFR < 30
upon diagnosis
Metabolic bone
disease

When to Refer to Nephrology

Timely referral to specialists, especially nephrology, for CKD patients allows for sufficient time to
plan and prepare patients for renal replacement therapy, if it is necessary.

It is recommended to refer to Nephrology if: (UW Health Low quality of evidence, strong
recommendation)
1.
a. eGFR<30 mL/min/1.73m
2

b. Persistent albuminuria (ACR >300 mg/g or UACR ≥30mg/g)
1

c. ≥ 20% decrease in eGFR
1

d. Secondary hyperparathyroidism
1

e. Persistent hyperkalemia/metabolic acidosis
1

f. Recurrent kidney stones
14

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13


g. Unexplained hematuria
1

h. Hereditary or unknown cause of CKD
1

i. CKD and hypertension refractory to treatment with ≥ 3 agents
1

j. Suspected renal artery stenosis
2. It is also recommended that any patient within Stage 4 CKD, regardless of cause, be
seen by a nephrology specialist as timely referral improves clinical outcomes and
reduces costs.
3
(UW Health Low quality of evidence, weak/conditional recommendation)
3. It is recommended that a CKD patient be seen by a nephrologist ≥ 12 months before
starting hemodialysis to discuss vascular access with the patient should renal
replacement therapy be required as referral > 4 months before initiating dialysis has a
survival benefit for patients who develop ESRD.
3,4,15
(KDIGO 1B)

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14


Provider Follow-Up
Table 5 suggests number of follow-up visits with measurements per year depending on the
patient’s CKD severity and also indicates when referral to Nephrology is recommended.

Table 5. Follow-Up Frequency and When to Consider Referral
16


Albuminuria Stage
A1 A2 A3
Stage
GFR
(ml/min/1.73m
2
)
<30mg/g
Normal to mildly
decreased
30-299 mg/g
Moderately
increased
≥300 mg/g
Severely
increased
G1
≥ 90
Normal or high
1 1 2
Refer
G2
60-89
Mildly decreased
1 1
2
Refer
G3a
45-59
Mildly to moderately
decreased
1 2
3
Refer
G3b
30-44
Moderately to
Severely decreased
2 3
3
Refer
G4
15-29
Severely decreased
3
Refer
3
Refer
4+
Refer
G5
< 15
Kidney failure
4+
Refer
4+
Refer
4+
Refer

Co-Management of Chronic Kidney Disease patients
When a patient’s chronic kidney disease progresses to late-stage CKD (i.e., Stage 4-5), care
shifts from focusing on preventing disease progression to preparing and planning for transplant,
dialysis and/or end stage renal disease and managing the complications of kidney disease (e.g.,
anemia, bone mineral disorders, etc.) Given the complexities of disease and healthcare costs, it
is increasingly important for primary care and nephrology services to work together to co-
manage CKD patients to ensure optimal outcomes. One noted barrier in managing late-stage
CKD is delayed referral to nephrology. In 2011, it was reported that 42.1% of incident dialysis
patients had never seen a nephrologist. To ensure optimal dialysis planning, it is vital for a
patient to be evaluated at least once by nephrology. Some literature suggestsa referral to
nephrology should occur at least 12 months prior to dialysis initiation, if not sooner.
15,17


To help facilitate monitoring and management of chronic kidney disease patients between
primary care and nephrology, Table 6 outlines suggested patient education topics to discuss
based on the patient’s kidney disease stage.


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15


Table 6. Suggested Patient Education and Renal Replacement Therapy Planning for
Chronic Kidney Disease Patients
GFR
(ml/min/1.73m
2
)
Patient Education Renal Replacement Therapy Planning
G1
GFR ≥ 90
• Counsel patient on importance blood
pressure control, lipid management and
glycemic control (e.g., diabetes)
• Emphasize medication adherence (e.g.,
antihypertensives) to prevent disease
progression
• Encourage lifestyle modifications to slow
progression of disease (e.g., physical
activity, smoking cessation)
• Counsel patient medications (OTC and
prescription) to be aware of Advise patient
to limit salt and eat less saturated and
trans fats foods

Education is recommended to all patients with
GFR < 60 and any patients with GFR > 60 and
CKD due to other factors (e.g., albuminuria.)

G2
GFR 60-89
G3a
GFR 45-59
G3b
GFR 30-44
• When GFR < 30 mL/min/1.73m2, in NON-
dominant arm, avoid blood pressure
measurements, IVs and blood draws
• Save veins/use hands for blood draws when
possible
• If patient GFR < 30 mL/min/1.73m2 and patient
has never been evaluated by nephrology,
consider nephrology referral
G4
GFR 15-29
• Have shared decision making
discussion/develop renal replacement
therapy plan, if needed
• Advise patient to register/attend for UW
Health Options Class
• Discuss whether patient is transplant
candidate
• Consider advanced care planning
discussion
• Consider palliative care discussion
• Consider transplant referral
• Think Peritoneal Dialysis first before
hemodialysis
• Ensure timely placement of fistula (referral to
vascular surgery)

G5
GFR < 15
• Advanced Care Planning
• Palliative Care discussion



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16


UW Health Implementation
Potential Benefits:
• Chronic kidney disease prevention
• Chronic kidney disease diagnosis
• Disease management
• Timely referral to Nephrology
Potential Harms:
• Loss of kidney function/end stage renal disease
• Medication side effects

Patient Resources
1. Health Facts For You #7143- Anemia of Chronic Kidney Disease

Companion Documents
1. Diagnosis and Management of Hypertenion – Adult – Ambulatory – Clinical Practice
Guideline
2. Standards of Medical Care in Diabetes – Adult/Pediatric – Inpatient/Ambulatory – Clinical
Practice Guideline
3. Anemia Management in Chronic Kidney Disease – Adult – Inpatient/Ambulatory – Clinical
Practice Guideline
4. Prevention of Contrast Induced Nephropathy – Adult – Inpatient/Ambulatory – Clinical
Practice Guideline

Guideline Metrics
1. Percentage of CKD stage 3-5 patients with ≥ 1 eGFR measurement in past 12 months.
2. Percentage of CKD stages 3-5 patients with ≥ 1 urine protein measurement in past 12
months.
3. Percentage of patients with CKD stages 4-5 with documented referral, scheduled
appointment, or completed visit with nephrologist in past 12 months.
4. Percentage of patients who attended UW Health Options class prior to dialysis initiation.

Implementation Plan/Clinical Tools
1. Guideline will be posted on uConnect in a dedicated location for Clinical Practice Guidelines.
2. Release of the guideline will be advertised in the Physician/APP Briefing newsletter.
3. Content and hyperlinks within clinical tools, documents, or Health Link related to the
guideline recommendations (such as the following) will be reviewed for consistency and
modified as appropriate.

Order Sets & Smart Sets
Kidney – Anemia Clinic [3258]

Delegation Protocols
Anemia Management in Pre-dialysis Chronic Kidney Disease Patients [20]

Disclaimer
Clinical practice guidelines assist clinicians by providing a framework for the evaluation and
treatment of patients. This guideline outlines the preferred approach for most patients. It is not
intended to replace a clinician’s judgment or to establish a protocol for all patients. It is
understood that some patients will not fit the clinical condition contemplated by a guideline and
that a guideline will rarely establish the only appropriate approach to a problem.
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17


Appendix A. Evidence Grading Schemes

Figure 1. GRADE Methodology adapted by UW Health


GRADE Ranking of Evidence
High We are confident that the effect in the study reflects the actual effect.
Moderate
We are quite confident that the effect in the study is close to the true effect, but it is also
possible it is substantially different.
Low The true effect may differ significantly from the estimate.
Very Low The true effect is likely to be substantially different from the estimated effect.

GRADE Ratings for Recommendations For or Against Practice
Strong
The net benefit of the treatment is clear, patient values and circumstances are
unlikely to affect the decision.
Weak/conditional
Recommendation may be conditional upon patient values and preferences, the
resources available, or the setting in which the intervention will be implemented.


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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

18


GRADE Methodology adapted by Kidney Disease Improving Global Outcomes (KDIGO)
Implications
Grade Patients Clinicians Policy
Level 1
“We recommend”
Most people in your
situation would want
the recommended
course of action and
only a small proportion
would not
Most patients should receive
the recommended course of
action.
The recommendation can
be evaluated as a
candidate for developing a
policy or a performance
measure.
Level 2
“We suggest”
The majority of people
in your situation would
want the
recommended course
of action, but many
would not.
Difference choices will be
appropriate for different
patients. Each patient
needs help to arrive at a
management decision
consistent with her or his
values and preferences.
The recommendation is
likely to require substantial
debate and involvement of
stakeholders before policy
can be determined.


Grade Quality of
Evidence
Meaning
A High We are confident that the true effect lies close to that of the
estimate of the effect.
B Moderate The true effect is likely to be close to the estimate of the effect, but
there is possibility that it is substantially different.
C Low The true effect may be substantially different from the estimate of
the effect.
D Very low The estimate of effect is very uncertain, and often will be far from
the truth.

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19



References

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Detection and Management of Chronic Kidney Disease for the Primary Care Clinician. Am J
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org