Primary care physicians are the front line of patient care. North Carolina has 900,000 citizens with chronic kidney disease (CKD) and there are 900,000 more North Carolinians at risk for developing CKD. The following resources are intended to help you access information about the risk factors for CKD and the most recent management guidelines and patient resources available.
- Early Diagnosis and Intervention: What Can You Do?
- What Are The Basic Components of a CKD Clinical Action Plan?
- What Treatments Are Recommended For Diabetes?
- What Are The New ICD-9 Codes?
- GFR Calculator
- Why is GFR so important?
- How can I request eGFR from my lab provider?
- How is CKD Managed in the HIV Infected Patient?
- More Useful Links
Early Diagnosis and Intervention: What Can You Do?
1. Determine risks
- Diabetes
- Hypertension
- Family history of diabetes, hypertension, CKD
- US Ethnic minority status
2. Do three simple tests
- Urinalysis to detect protein
- Blood Pressure
- Serum creatinine to estimate GFR
3. Implement action plan
- Click here to access the National Kidney Foundation's CKD Clinical
Action Plan
4. Consider Nephrology consult
5. Refer to Nephrologist when GFR < 30 ml/min/1.73m2
(Based on National Kidney Foundation recommended guidelines)
What Are The Basic Components of a CKD Clinical Action Plan?
The NKF web site has a a Clinical Action Plan tool which takes simple data that you enter, such as the patient's GFR, extent of kidney damage, dialysis, and comorbidities, to create a care plan for your CKD patient.
Click here to access the tool.
What Treatments Are Recommended For Diabetes?
New KDOQI Guidelines
All patients with diabetes should be screened for diabetic kidney disease (DKD). The guidelines emphasize diabetes prevention as well as screening and management of kidney disease and unveil a new term -- diabetic kidney disease or DKD -- which refers to the structural changes in the kidney that are specific to diabetes and can be detected by noninvasive tests, without the need for a biopsy because treatments that slow or prevent the disease and its complications are available.
These treatments include:
- Intensive glycemic control
- Antihypertensive therapies
- Cholesterol lowering
- Dietary protein restriction.
NKF guidelines, http://www.kidney.org/professionals/kdoqi/
What Are ICD-9 Codes for Chronic Kidney Disease?
Click here for a printable copy of the ICD-9 codes for CKD.
Why Is GFR So Important?
Information Provided by Abbott Laboratories
Why use eGFR vesus serum creatinine alone?
- The lack of sensitive and convenient markers of kidney function has been one difficulty traditionally faced by physicians in trying to identify patients with CKD in its early stages. Serum creatinine alone should not be used to assess the level of kidney function.
- Estimating GFR is a way to use Scr and factors associated with creatinine excretion (age, sex and ethnicity) to predict GFR.10
- The difference in calculated eGFRs in a cross-section of individuals with the same serum creatinine value.
(See example below.)
| Age |
Sex |
Race |
Scr (mg/dl) |
eGFR (mL/min/1.73 m2)10 |
CKD Stage |
|---|---|---|---|---|---|
| 20 |
M |
B |
1.3 |
91 (with kidney damage) |
1 |
| 20 |
M |
W |
1.3 |
75 (with kidney damage) |
2 |
| 55 |
M |
W |
1.3 |
61 (with kidney damage) |
2 |
| 20 |
F |
W |
1.3 |
56 |
3 |
| 55 |
F |
B |
1.3 |
55 |
3 |
| 50 |
F |
W |
1.3 |
46 |
3 |
B= black W= all ethnic groups other than black
**The rows highlighted in blue have a very different eGFR even though they have the same Scr.
How is eGFR used to diagnose and stage CKD?
The K/DOQI clinical practice guidelines define CKD based on one of two observations:
- Kidney damage for > 3 months, as defined by structural or functional abnormalities of the kidney, with or without decreased GFR manifested by either:
- Pathological abnormalities; or
- Markers of kidney damage, including abnormalities in the composition of blood or urine, or abnormalities in imaging tests
OR
- GFR < 60 mL/min/1.73m2 for > 3 months, with or without kidney damage
Once diagnosed with CKD, patients may be staged based on their eGFR according to the following K/DOQI classification. Action plans for the treatment of CKD patients are based on the stage of severity of CKD.
Stages of CKD : A Clinical Action Plan
| Stage |
Description |
eGFR |
Action* |
|---|---|---|---|
| 1 |
Kidney damage with normal or increased GFR |
>90 |
Diagnosis and treatment , treatment of co-morbid conditions, slowing progressions, cardiovascular disease risk reduction |
| 2 |
Kidney damage with normal or decreased GFR |
60-89 |
Estimating progression |
| 3 |
Moderately decreased GFR |
30-59 |
Evaluating and treating complications |
| 4 |
Severely decreased GFR |
15-29 |
Preparation for kidney replacement therapy |
| 5 | Kidney failure (ESKD) |
<15 | Replacement (if uremia present) |
*Includes actions from preceding stages
How can I request eGFR from my lab provider?
LabCorp
- Offers serum creatinine with eGFR using test code 100768
- To add eGFR calculation to all serum creatinine tests requested
by your office, contact your local sales representative or email: sales@LabCorp.com
Quest
- To order general chemistry tests w/ eGFR calculation
- Basic Metabolic Panel w/ eGFR, test code 15044
- Comprehensive Metabolic Panel w/ eGFR, test code 15045
- Serum Creatinine w/ eGFR, test code 11360
- For more information, contact your sales representative or visit: www.questdiagnostics.com
How is CKD Managed in the HIV Infected Patient?
Screening and Initial Evaluation Recommendations
- All patients at the time of HIV diagnosis should be assessed for existing kidney disease with a screening urine analysis for proteinuria and a calculated estimate of renal function
- If there is no evidence of proteinuria at initial evaluation, patients at high risk for the development of proteinuric renal disease should undergo annual screening. Renal function should be estimated on a yearly basis to assess for changes over time.
- Additional evaluations(including quantification of proteinuria, renal ultrasound, and potentially renal renal biopsy) and referral to a nephrologist are recommended for patients with proteinuria of grade >1+ by dipstick analysis or GFR<60 mL/min per 1.73m2.
Management
- In HIV-infected patients with evidence of nephropathy, blood pressure should be controlled to a level no higher than 125/75 mm Hg, with the initial preferential use of ACE inhibitors or ARBs for those patients with proteinuria. Calcium channel blockers should be avoided in patients receiving protease inhibitors.
- Dialysis and the placement of arteriovenous fistulae (native fistulae preferred) should not be withheld for patients solely because of HIV infection.
- Renal transplantation may be considered for patients with ESRD if provided in a supervised clinical trial or at centers with adequate experience to this area.
- Patients with HIVAN should be treated with HAART at diagnosis. HAART should not be withheld from patients simply because of the severity of their renal dysfunction.
- Addition of ACE inhibitors, ARBs and/or prednisone should be considered in patients with HIVAN if HAART alone does not result in improvement of renal function.
Antiretroviral Dosing and Renal Toxicities
- Appropriate reduction of dosing for antiretrovirals that are primarily renally eliminated is warranted, with additional doses given after hemodialysis for those drugs that are readily removed by dialysis.
- Nucleoside analogues should not be withheld in patients with reduced renal function for fear of the development of lactic acidosis.
- Patients receiving indinavir should drink at least 1.5 L of water daily to prevent stone formation. Periodic monitoring of renal function and pyuria should be performed during the first 6 months of indinavir therapy and biannually thereafter, although routine screening for crystalluria is not warranted unless there is a suspicion of nephrolithiasis. Indinavir need not be withheld from patients with reduced renal function. In patients who develop indinavir nephrolithiasis, it would be reasonable to restart indinavir therapy once rehydration is achieved. Patients who develop indinavir-induced hypertension, pyuria, rhabdomyolysis, or renal insufficiency (acute or chronic) should permanently discontinue use of this drug.
- Patients receiving tenofovir who have a GFR <90 mL/min per 1.73m2, patients receiving other medications eliminated via renal secretion (e.g., adefovir, acyclovir, ganciclovir, or cidofovir), patients with other comorbid diseases (e.g., diabetes or hypertension), or patients receiving ritonavir-boosted protease inhibitor regimens should be monitored at least biannually for measurements of renal function, serum phosphorus, and urine analysis for proteinuria and glycosuria.
Click HERE for the Complete Infectious Disease Society of America (IDSA) Guidelines
