Chapter 62: Chronic Kidney Disease

KEY CONCEPTS

• Chronic kidney disease (CKD) is classified based on the cause of kidney disease, assessment of glomerular filtration rate, and extent of albuminuria over at least a 3-month period.

• Guidelines from the Kidney Disease: Improving Global Outcomes (KDIGO) provide information to assist healthcare providers in clinical decision making and the design of appropriate therapy to manage CKD progression and the associated complications.

• Patient education and shared decision making play a critical role in the appropriate management of patients with CKD. Studies of multidisciplinary teams in CKD clinics have demonstrated significant benefits in slowing progression of CKD and reduced mortality.

• Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) are primary pharmacologic treatments to delay progression of CKD in patients with category A2-A3 albuminuria because of their effects on renal hemodynamics to reduce intraglomerular pressure and albuminuria.

• Sodium Glucose Transport-2 inhibitors (SGLT2i) have emerged as the latest treatment to prevent progression to later stages of CKD and ESRD in patients with Type 2 diabetes and other kidney diseases associated with albuminuria.

Patient Care Process for Chronic Kidney Disease (CKD)

Collect

• Patient characteristics (eg, age, CKD stage [see Fig. 62-1] and cause of CKD, medication allergies)

• Past medical history

• Social history (eg, smoking), family/friend supports

• Current medications including OTC (eg, NSAID use), herbals, dietary supplements

• Objective data:

  • Blood pressure, heart rate, weight

  • Labs as outlined in Table 62-4

Assess

• Serum creatinine, glomerular filtration rate (GFR), or creatinine clearance

• Presence of albuminuria (see Fig. 62-1)

• Serum potassium concentration—assess frequently in patients with CKD and heart failure requiring adjustment of diuretics and/or ACEI

• Blood pressure (see targets in Fig. 62-3)—consider use of home blood pressure monitor

• Insurance coverage of medications, current out of pocket cost of medications

• Medication adherence

• Potential drug interactions

• Need for renal dose adjustments

• Other recommendations as outlined in Table 62-2 (eg, vaccines, lifestyle modifications)

Plan

• Drug therapy recommendations, including dose, route, frequency, and duration

• Monitoring parameters, including frequency and timing of follow-up

• Patient education, including purpose of new or changed treatment, medication side effects, medication administration

• Self-monitoring for resolution of symptoms and blood pressure targets, medication to hold on sick days if vomiting or diarrhea occur (eg, ACEI/ARB; SGLT2 inhibitors)

• Referrals to other providers when appropriate (eg, dietitian, occupational therapist, social worker, endocrinologist, CKD clinic)

Implement*

• Provide patient education on all elements of the treatment plan

• Use motivational interviewing strategies to maximize adherence

• Schedule follow-up labs, adherence assessment

Follow-up: Monitor and Evaluate

• Resolution of CKD symptoms

• Presence of adverse effects (eg, dizziness, hypoglycemia)

• Patient adherence to treatment plan using multiple sources of information

BEYOND ...