Vous êtes sur la page 1sur 2

CKD ASSESSMENT

ALGORITHM
STOP
Patient
Office
Visit
No
Yes
Yes
Perform routine screening for CKD patients at increased risk
Serum creatinine to determine estimated GFR Microalbumin test Urinalysis for presence of white and red blood cells
Does patient have
abnormal GFR > 3 months?
Follow-up CKD monitoring
Test patients at risk for CKD annually
Counsel patients at risk for CKD but found not to
have CKD to reduce risk factors when possible
Yes
No
Does patient have elevated
albumin to creatinine ratio?
Diabetes: >30mg albumin/
lg creatinine
Non-diabetes: >300mg albumin/lg
creatinine
No
Is patient at risk for CKD?
Progressive Risk Factors
High levels proteinuria
Malignant hypertension
Poor glycemic control
Smoking
Hyperlipidemia
Drug use
Susceptibility
Age > 60 years
Family history of CKD
Racial/ethnic minority
Direct Risk Factors
Diabetes
High blood pressure
Autoimmune diseases
Lower urine tract
obstruction
Hx acute renal failure
Herbal remedies
Metabolic syndrome
Systemic infections
Urinary tract infection
Urinary stones
Drug toxicity
Exposure drugs/procedures
Stage 2
GFR 60-89
Stage 3
GFR 30-59
Stage 4
GFR 15-29
Stage 5
GFR <15
Begin CKD Treatment: develop clinical action plan
Collaborate with nephrologist to develop action plan to include:
Evaluate type of kidney disease
Evaluate and manage comorbid conditions (Primary care, all stages)
Slow the loss of kidney function (Co-management, all stages)
Prevent and treat cardiovascular disease (Primary care, all stages)
Prevent and treat complications of decreased kidney function (Co-management, all stages)
Prepare for kidney failure and replacement therapy (Nephrology, stage 4)
Replace kidney function (Nephrology, stage 5)
Consult nephrology if action plan cannot be performed or carried out when GFR < 60.
Review medication usage at follow-up visits
Evaluate for necessary dose adjustments based on level of kidney function
Evaluate for adverse effects of medications on kidney functions (NSAIDs, IV
contrast)
Evaluate for drug interactions
Counsel patient to avoid nephrotoxic drugs and IV contrast
Evaluate appropriateness for ARB/ACE inhibitor with diagnosis of hypertension
Evaluate need for therapeutic drug monitoring
Identify risks associated with CKD
Consider type of kidney disease
Evaluate complications of kidney disease:
anemia, hypertension, malnutrition, bone disease,
metabolic acidosis, congestive heart failure,
hyperkalemia, edema determined to be fluid
overload, neuropathy
Evaluate risk for loss of kidney function
Evaluate comorbid conditions
Evaluate risk for cardiovascular disease
Monitor CKD Progression
Annual microalbumin test
Track decline in GFR
Consult/refer to nephrologist
Consult nephrologist at Stage 1 if hematuria or significant
proteinuria present
Consult nephrologist at Stage 2 if GFR declines > 4mL/min/yr
Consult nephrologist at Stage 3 for all patients with CKD
Refer patient to nephrologist for evaluation when
GFR < 30 mL/min/1.73
2
Assess barriers to treatment adherence
Family and social support
Depression
Income and unemployment concerns
Stress and coping mechanisms
Perceptions of illness and treatment
Limited access to medications and/or care
Yes No
Determine
Stage of
CKD
Stage 1
GFR > 90
Kidney damage
Identification,
Treatment and Referral
Does patient have
abnormal GFR > 3 months?
P
r
i
m
a
r
y

C
a
r
e
A
s
s
e
s
s

C
o
m
p
l
i
c
a
t
i
o
n
s
L
a
b
s
B
P

m
o
n
i
t
o
r
i
n
g

q

6

m
o
.


G
F
R

q

1
2

m
o
.


U
r
i
n
a
l
y
s
i
s

q

1
2

m
o
.

t
o

a
s
s
e
s
s


h
e
m
a
t
u
r
i
a
,

p
r
o
t
e
i
n
u
r
i
a
,

m
i
c
r
o
a
l
b
u
m
i
n
u
r
i
a
L
i
p
i
d
s

q

1
2

m
o
.


I
f

d
i
a
b
e
t
i
c
,

H
g
b

A
1
C

a
n
d


m
i
c
r
o
a
l
b
u
m
i
n
u
r
i
a

q

1
2

m
o
.
R
i
s
k

A
s
s
e
s
s
m
e
n
t
A
v
o
i
d
a
n
c
e

o
f

n
e
p
h
r
o
t
o
x
i
c


a
g
e
n
t
s

a
n
d

d
y
e
s
I
m
m
u
n
i
c
a
t
i
o
n
s


F
l
u

v
a
c
c
i
n
e

q

1
2

m
o
.


P
n
e
u
m
o
v
a
x
,

a
s

i
n
d
i
c
a
t
e
d


H
e
p

B

v
a
c
c
i
n
e
,

a
s

i
n
d
i
c
a
t
e
d


A
s
s
e
s
s

c
a
r
d
i
o
v
a
s
c
u
l
a
r

r
i
s
k
:


S
m
o
k
i
n
g

c
e
s
s
a
t
i
o
n


P
h
y
s
i
c
a
l

a
c
t
i
v
i
t
y


E
d
u
c
a
t
i
o
n
C
a
r
d
i
o
v
a
s
c
u
l
a
r

r
i
s
k


M
e
d
i
c
a
t
i
o
n
s

t
o

a
v
o
i
d


I
m
m
u
n
i
z
a
t
i
o
n
s


P
r
i
m
a
r
y

C
a
r
e
A
s
s
e
s
s

C
o
m
p
l
i
c
a
t
i
o
n
s
L
a
b
s
B
P

m
o
n
i
t
o
r
i
n
g

q

3
-
1
2

m
o
.


G
F
R

q

1
2

m
o
.


U
r
i
n
a
l
y
s
i
s

q

3
-
1
2

m
o
.

t
o


a
s
s
e
s
s

h
e
m
a
t
u
r
i
a
,

p
r
o
t
e
i
n
u
r
i
a
,

m
i
c
r
o
a
l
b
u
m
i
n
u
r
i
a
L
i
p
i
d
s

q

1
2

m
o
.


I
f

d
i
a
b
e
t
i
c
,

H
g
b

A
1
C

a
n
d


m
i
c
r
o
a
l
b
u
m
i
n
u
r
i
a

q

1
2

m
o
.
H
g
b

q

1
2

m
o
.

i
f

>

1
1

g
m
/
d
L


R
i
s
k

A
s
s
e
s
s
m
e
n
t
A
v
o
i
d
a
n
c
e

o
f

n
e
p
h
r
o
t
o
x
i
c


a
g
e
n
t
s

a
n
d

d
y
e
s
I
m
m
u
n
i
c
a
t
i
o
n
s


F
l
u

v
a
c
c
i
n
e

q

1
2

m
o
.


P
n
e
u
m
o
v
a
x
,

a
s

i
n
d
i
c
a
t
e
d


H
e
p

B

v
a
c
c
i
n
e
,

a
s

i
n
d
i
c
a
t
e
d


A
s
s
e
s
s

c
a
r
d
i
o
v
a
s
c
u
l
a
r

r
i
s
k
:


S
m
o
k
i
n
g

c
e
s
s
a
t
i
o
n


P
h
y
s
i
c
a
l

a
c
t
i
v
i
t
y


E
d
u
c
a
t
i
o
n
C
a
r
d
i
o
v
a
s
c
u
l
a
r

r
i
s
k


M
e
d
i
c
a
t
i
o
n
s

t
o

a
v
o
i
d


I
m
m
u
n
i
z
a
t
i
o
n
s


C
o
-
M
a
n
a
g
e
m
e
n
t
A
s
s
e
s
s

C
o
m
p
l
i
c
a
t
i
o
n
s
L
a
b
s
B
P

m
o
n
i
t
o
r
i
n
g

q

3
-
1
2

m
o
.


G
F
R

q

3
-
1
2


m
o
.


U
r
i
n
a
l
y
s
i
s

q

6
-
1
2

m
o
.

t
o


a
s
s
e
s
s

h
e
m
a
t
u
r
i
a
,

p
r
o
t
e
i
n
u
r
i
a
,

m
i
c
r
o
a
l
b
u
m
i
n
u
r
i
a
L
i
p
i
d
s

q

2

m
o
.


I
f

d
i
a
b
e
t
i
c
,

H
g
b

A
1
C

a
n
d


m
i
c
r
o
a
l
b
u
m
i
n
u
r
i
a

q

1
2

m
o
.
H
g
b


>

1
1

q

3
-
6

m
o
.


H
g
b

<

1
1

q

1
-
3

m
o
.


L
y
t
e
s

a
n
d

g
l
u
c
o
s
e

q

1
2

m
o
.


P
T
H
,

C
a

&

P

q

3
-
1
2

m
o
.


M
e
a
s
u
r
e

2
5

(
O
H
)
D


R
i
s
k

A
s
s
e
s
s
m
e
n
t
A
v
o
i
d
a
n
c
e

o
f

n
e
p
h
r
o
t
o
x
i
c


a
g
e
n
t
s

a
n
d

d
y
e
s
I
m
m
u
n
i
z
a
t
i
o
n
s


F
l
u

v
a
c
c
i
n
e

q

1
2

m
o
.


P
n
e
u
m
o
v
a
x
,

a
s

i
n
d
i
c
a
t
e
d


H
e
p

B

v
a
c
c
i
n
e
,

a
s

i
n
d
i
c
a
t
e
d


A
s
s
e
s
s

c
a
r
d
i
o
v
a
s
c
u
l
a
r

r
i
s
k
:


S
m
o
k
i
n
g

c
e
s
s
a
t
i
o
n


P
h
y
s
i
c
a
l

a
c
t
i
v
i
t
y


E
d
u
c
a
t
i
o
n
C
a
r
d
i
o
v
a
s
c
u
l
a
r

r
i
s
k


M
e
d
i
c
a
t
i
o
n
s

t
o

a
v
o
i
d


I
m
m
u
n
i
z
a
t
i
o
n
s


N
u
t
r
i
t
i
o
n
:

A
d
v
i
s
e

d
i
e
t

l
o
w

i
n

s
a
l
t


a
n
d

p
o
t
a
s
s
i
u
m
R
e
n
a
l

b
o
n
e

d
i
s
e
a
s
e


N
e
p
h
r
o
l
o
g
y
A
s
s
e
s
s

C
o
m
p
l
i
c
a
t
i
o
n
s
L
a
b
s
B
P

m
o
n
i
t
o
r
i
n
g

q

3
-
6

m
o
.


G
F
R

q

3
-
6

m
o
.


L
i
p
i
d
s

q

1
2

m
o
.


I
f

d
i
a
b
e
t
i
c
,

H
g
b

A
1
C

a
n
d

s
p
o
t


u
r
i
n
e

f
o
r

p
r
o
t
e
i
n

c
r
e
a
t
i
n
i
n
e


r
a
t
i
o

q

3
-
6

m
o
.
H
g
b

q

3
-
6

m
o
.
,

m
o
n
t
h
l
y

i
f

o
n


E
S
A

t
h
e
r
a
p
y
P
T
H
,

C
a
,

P
.

q

3
-
6

m
o
.


M
e
a
s
u
r
e

2
5
(
O
H
)
D


R
i
s
k

A
s
s
e
s
s
m
e
n
t
A
v
o
i
d
a
n
c
e

o
f

n
e
p
h
r
o
t
o
x
i
c


a
g
e
n
t
s

a
n
d

d
y
e
s
I
m
m
u
n
i
z
a
t
i
o
n
s


F
l
u

v
a
c
c
i
n
e

q

1
2

m
o
.


P
n
e
u
m
o
v
a
x
,

a
s

i
n
d
i
c
a
t
e
d


H
e
p

B

v
a
c
c
i
n
e
,

a
s

i
n
d
i
c
a
t
e
d


A
s
s
e
s
s

c
a
r
d
i
o
v
a
s
c
u
l
a
r

r
i
s
k
:


S
m
o
k
i
n
g

c
e
s
s
a
t
i
o
n


P
h
y
s
i
c
a
l

a
c
t
i
v
i
t
y


E
d
u
c
a
t
i
o
n
C
a
r
d
i
o
v
a
s
c
u
l
a
r

r
i
s
k


M
e
d
i
c
a
t
i
o
n
s

t
o

a
v
o
i
d


I
m
m
u
n
i
z
a
t
i
o
n
s


N
u
t
r
i
t
i
o
n
:

A
d
v
i
s
e

d
i
e
t

l
o
w

i
n

s
a
l
t
,


p
h
o
s
,

a
n
d

p
o
t
a
s
s
i
u
m
R
e
n
a
l

b
o
n
e

d
i
s
e
a
s
e


A
n
e
m
i
a


V
a
s
c
u
l
a
r

a
c
c
e
s
s

p
l
a
c
e
m
e
n
t


M
o
d
a
l
i
t
y

o
p
t
i
o
n
s


R
e
f
e
r
r
a
l
s
S
u
r
g
e
o
n

f
o
r

v
a
s
c
u
l
a
r

a
c
c
e
s
s


p
l
a
c
e
m
e
n
t
T
r
a
n
s
p
l
a
n
t

c
e
n
t
e
r

f
o
r

e
v
a
l


N
e
p
h
r
o
l
o
g
y
A
s
s
e
s
s

C
o
m
p
l
i
c
a
t
i
o
n
s
L
a
b
s
G
F
R

q

1
-
3

m
o
.


L
i
p
i
d
s

q

1
2

m
o
.


I
f

d
i
a
b
e
t
i
c
,

H
g
b

A
1
C

a
n
d

s
p
o
t


u
r
i
n
e

f
o
r

p
r
o
t
e
i
n

c
r
e
a
t
i
n
i
n
e


r
a
t
i
o

q

3
-
6

m
o
.
H
g
b

m
o
n
t
h
l
y


P
T
H
,

C
a
,

P

q

1
-
3

m
o
.


M
e
a
s
u
r
e

2
5

(
O
H
)
D


H
B
V

t
i
t
e
r


R
i
s
k

A
s
s
e
s
s
m
e
n
t
A
v
o
i
d
a
n
c
e

o
f

n
e
p
h
r
o
t
o
x
i
c


a
g
e
n
t
s

a
n
d

d
y
e
s
I
m
m
u
n
i
z
a
t
i
o
n
s


F
l
u

v
a
c
c
i
n
e

q

1
2

m
o
.


P
n
e
u
m
o
v
a
x
,

a
s

i
n
d
i
c
a
t
e
d


H
e
p

B

v
a
c
c
i
n
e
,

a
s

i
n
d
i
c
a
t
e
d


A
s
s
e
s
s

c
a
r
d
i
o
v
a
s
c
u
l
a
r

r
i
s
k
:


S
m
o
k
i
n
g

c
e
s
s
a
t
i
o
n


P
h
y
s
i
c
a
l

a
c
t
i
v
i
t
y


E
d
u
c
a
t
i
o
n
C
a
r
d
i
o
v
a
s
c
u
l
a
r

r
i
s
k


M
e
d
i
c
a
t
i
o
n
s

t
o

a
v
o
i
d


I
m
m
u
n
i
z
a
t
i
o
n
s


N
u
t
r
i
t
i
o
n
:

A
d
v
i
s
e

d
i
e
t

l
o
w

i
n


f
l
u
i
d
s
,

s
a
l
t
,

p
h
o
s

a
n
d

p
o
t
a
s
s
i
u
m
R
e
n
a
l

b
o
n
e

d
i
s
e
a
s
e


A
n
e
m
i
a


V
a
s
c
u
l
a
r

a
c
c
e
s
s

m
o
n
i
t
o
r
i
n
g


M
o
d
a
l
i
t
y

o
p
t
i
o
n
s


E
v
a
l
u
a
t
i
o
n

f
o
r

k
i
d
n
e
y

t
r
a
n
s
p
l
a
n
t


R
e
f
e
r
r
a
l
s
S
u
r
g
e
o
n

f
o
r

v
a
s
c
u
l
a
r

a
c
c
e
s
s


i
n
t
e
r
v
e
n
t
i
o
n
,

a
s

n
e
e
d
e
d
T
r
a
n
s
p
l
a
n
t

c
e
n
t
e
r

f
o
r

e
v
a
l


C
K
D

T
R
E
A
T
M
E
N
T

A
L
G
O
R
I
T
H
M
C
K
D

S
t
a
g
e

1
G
F
R

>

9
0
m
L
/
m
i
n
/
1
.
7
3
m
2
C
K
D

S
t
a
g
e

2
G
F
R

6
0

8
9
m
L
/
m
i
n
/
1
.
7
3
m
2
C
K
D

S
t
a
g
e

3
G
F
R

3
0

5
9
m
L
/
m
i
n
/
1
.
7
3
m
2
C
K
D

S
t
a
g
e

4
G
F
R

1
5

2
9
m
L
/
m
i
n
/
1
.
7
3
m
2
C
K
D

S
t
a
g
e

5
G
F
R

<

1
5
m
L
/
m
i
n
/
1
.
7
3
m
2
M
O
-
0
9
-
2
5

C
K
D

A
p
r
i
l

2
0
0
9

T
h
i
s

m
a
t
e
r
i
a
l

w
a
s

p
r
e
p
a
r
e
d

b
y

P
r
i
m
a
r
i
s
,

t
h
e

M
e
d
i
c
a
r
e

Q
u
a
l
i
t
y

I
m
p
r
o
v
e
m
e
n
t

O
r
g
a
n
i
z
a
t
o
n

f
o
r

M
i
s
s
o
u
r
i
,

u
n
d
e
r

c
o
n
t
r
a
c
t

w
i
t
h

t
h
e

C
e
n
t
e
r
s

f
o
r

M
e
d
i
c
a
r
e

&

M
e
d
i
c
a
i
d

S
e
r
v
i
c
e
s

(
C
M
S
)
,

a
n

a
g
e
n
c
y

o
f

t
h
e

U
.
S
.

D
e
p
a
r
t
m
e
n
t

o
f

H
e
a
l
t
h

a
n
d

H
u
m
a
n

S
e
r
v
i
c
e
s
.

T
h
e

c
o
n
t
e
n
t
s

p
r
e
s
e
n
t
e
d

d
o

n
o
t

n
e
c
e
s
s
a
r
i
l
y

r
e
f
e
c
t

C
M
S

p
o
l
i
c
y
.
R
e
p
r
i
n
t
e
d

w
i
t
h

p
e
r
m
i
s
s
i
o
n

f
r
o
m

T
M
F

H
e
a
l
t
h

Q
u
a
l
i
t
y

I
n
s
t
t
u
t
e
.