CHRONIC KIDNEY DISEASE PRACTICE GUIDELINES

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1 CHRONIC KIDNEY DISEASE PRACTICE GUIDELINES Reviewed and approved 5/2014 Risk Chronic kidney disease is defined as either kidney damage or decreased kidney function (decreased GFR) for 3 or more months. The differential diagnosis of CKD is based on history, physical exam and laboratory evaluation. Diabetic kidney disease is the largest single cause of kidney failure, however, non-diabetic kidney diseases include glomerular, vascular, tubulointerstitial and cystic kidney diseases. Definition Glomerular filtration rate is the best measure of overall kidney function in health and disease. The normal level of GFR varies according to age, sex, and body size. Normal GFR in young adults is approximately 120 to 130 ml/min per 1.73 m2 and declines with age. A GFR level less than 60 ml/min per 1.73 m2 represents loss of half or more of the adult level of normal kidney function. Below this level, the prevalence of complications of chronic kidney disease increases. Risk Factors Although the age-related decline in GFR has been considered part of normal aging, decreased GFR in the elderly is an independent predictor of adverse outcomes, such as death and CVD. In addition, decreased GFR in the elderly requires adjustment in drug dosages, as in other patients with chronic kidney disease. Therefore, the definition of chronic kidney disease is the same, regardless of age. Because GFR declines with age, the prevalence of chronic kidney disease increases with age; approximately 17% of persons older than 60 years of age have an estimated GFR less than 60 ml/min per 1.73 m 2. Susceptibility factors (Increase susceptibility to kidney damage) : Older age, family history of chronic kidney disease, reduction in kidney mass, low birth weight, U.S. racial or ethnic minority status, low income or education Initiation factors (Directly initiate kidney damage): Diabetes, high blood pressure, autoimmune diseases, systemic infections, urinary tract infections, urinary stones, lower urinary tract obstruction, drug toxicity Progression factors (Cause worsening kidney damage and faster decline in kidney function after initiation of kidney damage) : Higher level of proteinuria, higher blood pressure, poor glycemic control in diabetes, smoking, and hyperlipidemia 1 SummaCare Clinical Care Guidelines

2 End-stage factors (Increase morbidity and mortality in kidney failure): Lower dialysis dose (Kt/V), temporary vascular access, anemia, low serum albumin level, late referral Treatment can slow the progression to kidney failure. Thus, measures to prevent, detect, and treat chronic kidney disease in its earlier stages could reduce the adverse outcomes of chronic kidney disease. Goal Decreased GFR is associated with a wide range of complications, such as hypertension, anemia, malnutrition, bone disease, neuropathy, and decreased quality of life, which can be prevented or ameliorated by treatment at earlier stages. Cardiovascular disease deserves special consideration as a complication of chronic kidney disease because 1) CVD events are more common than kidney failure in patients with chronic kidney disease, 2) chronic kidney disease seems to be a risk factor for CVD, and 3) CVD in patients with chronic kidney disease is treatable and potentially preventable. Diabetes deserves special consideration as a contributing factor because it is the leading cause of CKD. There is no direct evidence that addresses whether systematic CKD screening improves clinical outcomes. Screening 5 Stages of CKD Monitoring for Research recommendations: Target populations with high CKD prevalence and high risk for complications. May test different screening measures (e.g. microalbuminuria, macroalbuminuria, egfr, or combination). Measurement of creatinine clearance by using timed (i.e. 24-hour) urine collections, does not provide more accurate estimates of GFR than do prediction equations for most people, except at extremes of age and weight. Under most circumstances, untimed urine samples should be used to detect and monitor proteinuria. Stage I: Kidney damage with GFR > 90 ml/min/1.73 m 2 Stage 2: Kidney damage with GFR ml/min/1.73 m 2 Stage 3: GFR ml/min/1.73 m 2 regardless of kidney damage Stage 4: GFR ml/min/1.73 m 2 regardless of kidney damage Stage 5: GFR < 15 ml/min/1.73 m 2 regardless of kidney damage or kidney failure treated by dialysis or transplantation. JNC7 Recommends annual quantitative measurement of albuminuria in all 2 SummaCare Clinical Care Guidelines

3 Progression Treatment patients with kidney disease. KDOQI also recommends more frequent monitoring of CKD patients with worsening kidney function. Treatment is designed to delay the progression of the disease to kidney failure. Patients with proteinuria (macroalbuminuria), diabetes and hypertension may benefit from ACEI and/or ARB treatment. Early intervention may reduce risk of mortality or ESRD. Patients who have microalbuminuria are at high risk for cardiovascular complications and may benefit from ACEI treatment at adequate doses. Early screening for impaired egfr or creatinine clearance could lead to early initiation of statin treatment and reduced risk of mortality, MI or stroke. Statin therapy should be considered in patients with hyperlipidemia. Beta blockers significantly reduce the risk of mortality, MI and CHF events in patients with CHF and impaired egfr.patients with systolic CHF already have an indication for beta blockers, regardless of whether they have CKD. Low-protein diet does not significantly reduce risk of mortality, ESRD or any clinical vascular outcome compared with usual protein diet. Screening for tobacco use and treatment and/or counseling for tobacco cessation Glycemic control for patients with diabetes Blood Pressure Control Goal: <130/80 mm Hg Medical Therapy First line pharmaceutical agent is an ACE inhibitor either alone or in conjunction with thiazide diuretic. ARB may be substituted for an ACE in cases where ACE is contraindicated or not tolerated. Blood pressure should be measured at every routine visit. Inquire about cardiovascular risk factors. Feel pulses and listen for bruits each visit. Steroids and/or immunosuppressant medication may be indicated for glomerulonephritis. Certain patients with CKD may require other medications such as: A phosphate binder if the kidneys are unable to eliminate phosphate. Vitamin D2 and/or active Vitamin D3 analog to prevent bone loss Erythropoetin to build red blood cells if anemic and iron replete. Yearly influenza vaccination for all chronic kidney disease patients. Hepatitis B vaccination series recommended for chronic kidney disease patients. 3 SummaCare Clinical Care Guidelines

4 Pneumococcal vaccine in patients with end stage renal disease. A CKD diet limits sodium to prevent swelling and high blood pressure and in certain patients, restricts protein to prevent elevated urea in the blood. It also balances calcium and phosphorus to prevent bone loss and helps maintain proper potassium levels to prevent a potentially fatal arrhythmia. Dietary guidelines Nutritional supplements may be added to ensure enough calories are taken. If the patient has diabetes, the primary source of calories is simple carbohydrates. Counseling on weight management. Diabetes education as appropriate If kidney function drops below a GFR of 20, evaluation for kidney transplantation should be considered. All patients must be educated about all options for renal replacement therapy. Dialysis and Transplantation If patient is not considered a candidate for transplantation, dialysis should be started when GFR reaches 10, or earlier. (15 in patients with Diabetes) If there is diabetic nephropathy, patient may be a candidate for a new pancreas along with a kidney, eliminating the need for insulin and other diabetes medication. Vaccination for pneumonia, hepatitis B, and influenza should be considered in all patients with end stage renal disease. 4 SummaCare Clinical Care Guidelines

5 Sources: Chronic Kidney Disease Stages 1-3: Screening, Monitoring and Treatment. Comparative Effectiveness Review, Number Immunizations in Patients with End Stage Renal Disease, March Chronic Kidney Disease Treatment Guide; Glickman Urologic and Kidney Institute, Cleveland Clinic, Guidelines reviewed/updated: 8/2/2012 Developed and approved by Clinical Quality and Resource Management Committee 5/8/2014 Medical Policy Committee Meeting 5 SummaCare Clinical Care Guidelines