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Disclaimer: The Chronic Kidney Disease Management Tool is designed with the aim to assist healthcare professionals in providing quality treatment for patients with diabetic nephropathy. It is intended to be an easy-to-use, practical clinical decision support too for the treatment of diabetic nephropathy. It is stressed that it cannot replace the clinical judgment of a healthcare professional. The author holds no responsibility what so ever for any potentially incorrect treatment following the usage of the tool. We ask you carefully to make sure you have selected the right options so that the calculator uses the formulas you intend/need to use for your patient's clinical situation.

Chronic Kidney Disease Management Tool

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Renal Management Plan

Suggested Renal Management in CKD stage 1

Almost all patients with stages 1 CKD can be managed by the primary care physicians. Apart from control of the diabetes, look out for risks of progressive renal disease and reduce the associated risks.

12 monthly estimation of

• eGFR - consider referral if there is significant deterioration in eGFR. A significant deterioration has been variously defined as a short-term eGFR fall of >15% or a loss in GFR over 5ml/min/year
• Urinary for albumin/creatinine ratio - ACR or protein/creatinine ratio PCR. If ACR >70 mg/g or PCR >100 mg/g, refer to specialist for review
• Blood pressure - Maintain blood pressure <140/90 mm Hg, for patients with urinary ACR>30 mg/g or PCR>50 mg/g, maintain blood pressure <130/80 mm Hg. Use angiotensin converting enzyme inhibitors ACEI/ angiotensin receptor blockers ARB as first line unless there is contraindication
• Cardiovascular risk - advice on smoking, exercise and lifestyle. Consider cholesterol lowering therapy if already have macrovascular disease, or if estimated 10-year risk of cardiovascular events =/>20%

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Diabetic Management Plan (for patients with diabetes mellitus)

Suggested diabetic intervention in CKD stage 1

1. Life style modifications
2. Metformin as first line of treatment
3. Consider add on Sulphonylurea
4. Consider add on DDP4 inhibitors (eg vildagliptin, sitagliptin, saxaglitpin, linaglyptin) instead of sulphonylurea if there is significant risk of hypoglycaemia or if sulphonylurea is contraindicated
5. Consider add on SGLT2 inhibitors (eg dapagliflozin, canagliflozin, empagliflozin)
6. Consider insulin
7. Consider statin if LDC cholesterol >2.6 mmol/l despite lifestyle modifications

Renal Management Plan

Suggested Renal Management in CKD stage 2

Initial assessment

AAlmost all patients with CKD stage 2 can be managed by the primary care physician. Apart from control of the diabetes, identify risk factors for progressive renal disease and to reduce associated risks.

12 monthly estimation of

• eGFR - consider referral if there is significant deterioration in eGFR. A significant deterioration has been defined as a short-term eGFR fall of >15% or loss in GFR over 5ml/min/year/li>
• Urinary for albumin/creatinine ratio - ACR or protein/creatinine ratio PCR. If ACR >70 mg/g or PCR >100 mg/g, refer specialist for review
• Blood pressure - Maintain blood pressure <140/90 mm Hg, for patients with urinary ACR>30 mg/g or PCR>50 mg/g, maintain blood pressure <130/80 mm Hg. Use angiotensin converting enzyme inhibitors ACEI/ angiotensin receptor blockers ARB as first line unless there is contraindication
• Cardiovascular risk - advice on smoking, exercise and lifestyle. Consider cholesterol lowering therapy if already have macrovascular disease, or if estimated 10-year risk of cardiovascular events =/>20%

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Diabetic Management Plan (for patients with diabetes mellitus)

Suggested diabetic intervention in CKD stage 2

1. Life style modifications
2. Metformin as first line of treatment
3. Consider add on Sulphonylurea
4. Consider on DDP4 inhibitors (eg vildagliptin, sitagliptin, saxaglitpin, linagliptin) instead of sulphonylurea if there is significant risk of hypoglycaemia or sulphonylurea is contraindicated
5. Consider add on SGLT2 inhibitors (eg dapagliflozin, canagliflozin, empagliflozin)
6. Consider insulin
7. Consider statin if LDC cholesterol >2.6 mmol/l despite lifestyle modifications

Diabetic Management Plan (for patients with diabetes mellitus)

Suggested diabetic intervention in CKD stage 3A

1. Lifestyle modifications
2. Metformin should be used with caution for fear of lactic acidosis, not advised if eGFR <40 ml/minute
3. Sulphonylurea used with caution especially those with long half-life to avoid hypoglycaemia
4. Consider DPP4 inhibitors (eg vildagliptin, sitagliptin, saxaglitpin, linagliptin), with the exception of linagliptin, the dose might need to be reduced
5. Consider insulin
6. Consider statins if LDC cholesterol >2.6 mmol/l despite lifestyle modifications

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Renal Management Plan

Suggested Renal Management in CKD stage 3A

Most CKD Stage 3A patients can be managed by the primary care physicians. The aim is to identify individuals at risk of progressive renal disease and to reduce associated risks.

Risk of cardiovascular events and death is substantially increased by the presence of CKD. The risk of cardiovascular death is (on average) much higher than the risk of needing dialysis or a renal transplant.

Identify patients with increased risk of progression to end stage renal failure (Stage 5). Indicators of progression of renal disease are:

• Proteinuria - the risk is graded, but a common cut-off for investigation is albumin/creatinine ratio ACR>70 mg/g or protein/creatinine ratio PCR>100 mg/g
• Declining eGFR
• Young age

Initial assessment of stage 3A CKD

Clinical assessment - in addition to the diabetic control, exclude sepsis, heart failure, hypovolaemia, etc. Renal ultrasonogram recommended to exclude obstruction.

6 then 12 monthly estimation of

• eGFR and K - consider an unexplained fall in eGFR of >25% to be acute on chronic renal failure. Specialist referral for a loss in GFR over 5ml/min/year
• Hb - if low, exclude non-renal cause. Below 110 g/l, specific therapy may be considered. Hb falls progressively as GFR falls, but renal anaemia rarely becomes significant before stage 3B or 4 CKD
• Urinary for albumin/creatinine ratio - ACR or protein/creatinine ratio PCR. IF ACR >70 mg/g or PCR >100 mg/g, refer specialist for review
• Blood pressure - Maintain blood pressure < 140/90 mm Hg (For patients with urinary ACR>30 mg/g or PCR>50 mg/g, maintain blood pressure <130/80 mm Hg. Use angiotensin converting enzyme inhibitors ACEI/ angiotensin receptor blockers ARB as first line unless there is contraindication
• Cardiovascular risk - advice on smoking, exercise and lifestyle. Consider cholesterol lowering therapy if already have macrovascular disease, or if estimated 10-year risk of cardiovascular events =/>20%
• Immunization - influenza and pneumococcal
• Medication review - regular review of medication to minimize nephrotoxic drugs (particularly NSAIDs) and ensure doses of others are appropriate to renal function

Diabetic Management Plan (for patients with diabetes mellitus)

Suggested diabetic intervention in CKD stage 3B

1. Lifestyle modifications
2. Metformin should be used with caution for fear of lactic acidosis, not advised if eGFR <40 ml/minute
3. Sulphonylurea used with caution especially those with long half-life to avoid hypoglycaemia
4. Consider DPP4 inhibitors (eg vildagliptin, sitagliptin, saxaglitpin, linagliptin), with the exception of linagliptin, the dose might need to be reduced
5. Consider insulin
6. Consider statins if LDC cholesterol >2.6 mmol/l despite lifestyle modifications

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Renal Management Plan

Suggested Renal Management in CKD stage 3B

Most CKD Stage 3B patients can be managed by the primary care physicians. The aim is to identify individuals at risk of progressive renal disease and to reduce associated risks.

Risk of cardiovascular events and death is substantially increased by the presence of CKD. The risk of cardiovascular death is (on average) much higher than the risk of needing dialysis or a renal transplant.

Identify patients with increased risk of progression to end stage renal failure (Stage 5). Indicators of progression of renal disease are:

• Proteinuria - the risk is graded, but a common cut-off for investigation is albumin/creatinine ratio ACR>70 mg/g or protein/creatinine ratio PCR>100 mg/g
• Declining eGFR
• Young age

Initial assessment of stage 3B CKD

Clinical assessment - in addition to the diabetic control, exclude sepsis, heart failure, hypovolaemia, etc. Renal ultrasonogram recommended to exclude obstruction.

6 then 12 monthly estimation of

• eGFR and K - consider an unexplained fall in eGFR of >25% to be acute on chronic renal failure. Specialist referral for a loss in GFR over 5ml/min/year
• Hb - if low, exclude non-renal cause. Below 110 g/l, specific therapy may be considered. Hb falls progressively as GFR falls, but renal anaemia rarely becomes significant before stage 3B or 4 CKD
• Urinary for albumin/creatinine ratio - ACR or protein/creatinine ratio PCR. IF ACR >70 mg/g or PCR >100 mg/g, refer specialist for review
• Blood pressure - Maintain blood pressure < 140/90 mm Hg (For patients with urinary ACR>30 mg/g or PCR>50 mg/g, maintain blood pressure <130/80 mm Hg. Use angiotensin converting enzyme inhibitors ACEI/ angiotensin receptor blockers ARB as first line unless there is contraindication
• Cardiovascular risk - advice on smoking, exercise and lifestyle. Consider cholesterol lowering therapy if already have macrovascular disease, or if estimated 10-year risk of cardiovascular events =/>20%
• Immunization - influenza and pneumococcal
• Medication review - regular review of medication to minimize nephrotoxic drugs (particularly NSAIDs) and ensure doses of others are appropriate to renal function

Renal Management Plan

Suggested Renal Management in CKD stage 4

Stage 4 CKD is severely reduced kidney function, 15-30% (eGFR 15-29ml/min/1.73m²)

Initial assessment

Clinical assessment - in addition to the diabetic control, exclude sepsis, heart failure, hypovolaemia, etc. Renal ultrasonogram recommended to exclude obstruction if not already done before.

Refer to specialist for in preparation for renal dialysis/transplantation.

3 monthly estimation of

• eGFR and K - hyperkalaemia that is severe or not responsive to changes in therapy should lead to discussion or referral
• Hb - if low, exclude non-renal cause
• Ca and phosphate - Oral phosphate binders will often be necessary
• Urinary for albumin/creatinine ratio ACR or protein/creatinine ratio PCR. IF ACR >70 mg/g or PCR >100 mg/g, refer specialist for review
• Blood pressure - Maintain blood pressure <140/90 mm H. For patients with urinary ACR>30 mg/g or PCR>50 mg/g, maintain blood pressure <130/80 mm Hg. Use angiotensin converting enzyme inhibitors ACEI/ angiotensin receptor blockers ARB as first line unless there is contraindication
• Cardiovascular risk - advice on smoking, exercise and lifestyle. Consider cholesterol lowering therapy if already have macrovascular disease, or if estimated 10-year risk of cardiovascular events =/>20%
• Immunization - influenza and pneumococcal, plus hepatitis B immunization if renal replacement therapy contemplated
• Medication review - regular review of medication to minimize nephrotoxic drugs (particularly NSAIDs) and ensure doses of others are appropriate to renal function

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Diabetic Management Plan (for patients with diabetes mellitus)

Suggested diabetic intervention in CKD stage 4

1. Lifestyle modifications
2. Metformin contraindicated
3. Sulphonylurea used with caution to avoid hypoglycaemia
4. Consider insulin
5. Consider DDP4 inhibitors (eg vildagliptin, sitagliptin, saxaglitpin, linagliptin). With the exception of linagliptin, the dose might need to be reduced
6. Consider statins if LDC cholesterol >2.6 mmol/l despite lifestyle modifications

Renal Management Plan

Suggested Renal Management in CKD stage 5

Stage 5 CKD is very severely reduced kidney function (end stage renal failure or ESRD), less than 15% (eGFR less than 15 ml/min).

Initial assessment

Clinical assessment - in addition to the diabetic control, exclude sepsis, heart failure, hypovolaemia, etc. Renal ultrasonogram recommended to exclude obstruction if not already done before.

Refer to specialist for dialysis or transplantation.

3 monthly estimation of

• eGFR and K - hyperkalaemia that is severe or not responsive to changes in therapy should lead to discussion or referral
• Hb - if low, exclude non-renal cause
• Ca and phosphate - Oral phosphate binders will often be necessary
• Urinary for albumin/creatinine ratio - ACR or protein/creatinine ratio PCR. IF ACR >70 mg/g or PCR> 100 mg/g, refer to specialist for review
• Blood pressure - maintain blood pressure <140/90 mm Hg(130-139/90), For patients with: urinary ACR>30 mg/g or PCR>50 mg/g, maintain blood pressure <130/80 mm Hg
• Cardiovascular risk - advice on smoking, exercise and lifestyle. Consider cholesterol lowering therapy if already have macrovascular disease, or if estimated 10-year risk of cardiovascular events =/>20%
• Immunization - influenza and pneumococcal, plus hepatitis B immunization if renal replacement therapy contemplated
• Medication review - regular review of medication to minimize nephrotoxic drugs (particularly NSAIDs) and ensure doses of others are appropriate to renal function

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Diabetic Management Plan (for patients with diabetes mellitus)

Suggested diabetic intervention in CKD stage 5

1. Lifestyle modifications
2. Metformin contraindicated
3. Sulphonylurea used with caution to avoid hypoglycaemia
4. Consider DDP4 inhibitors (eg vildagliptin, sitagliptin, saxaglitpin, linagliptin) in reduced dose. With the exception of linagliptin, the dose might need to be reduced
5. Consider insulin
6. Consider statins if LDC cholesterol >2.6 mmol/l despite lifestyle modifications