GP ACTION PLAN-CHRONIC KIDNEY DISEASE (RED)
Macroalbuminuria irrespective of eGFR or
eGFR < 30 mL/min/1.73m2 irrespective of albuminuria
Goals of management
  • Investigations to determine underlying cause
  • Reduce progression of Kidney disease
  • Assessment of Absolute Cardiovascular Risk
  • Avoidance of nephrotoxic medications or volume depletion
  • Early detection and management of complications
  • Adjustment of medication doses to levels appropriate kidney function
  • Appropriate referral to a Nephrologist when indicated
  • Prepare for kidney replacement therapy if appropriate
  • Prepare for non -dialysis supportive care is appropriate

Patient Details
Do you identify as Aboriginal and/or Torres Strait Islander? Yes No
Patient’s Name:
Sex: Male Female
DOB:
Address:
Medicare No: / General Practitioner’s Details
Doctor Name:
Practice:
Address:
Provider No:
Carer’s Details (if appropriate) / Date:

This Management Plan covers your multiple Chronic Conditions with a focus on Kidney Disease

Patient problems / needs / relevant conditions

PAST MEDICAL HISTORY

<Clinical Details: History List>

FAMILY HISTORY

<Clinical Details: Family History>

SOCIAL HISTORY

<Clinical Details: Social History>

MEDICATIONS

<Clinical Details: Medication List>

ALLERGIES

<Clinical Details: Allergies>

IMMUNISATIONS

<Clinical Details: Immunisations>

Patient needs/ relevant conditions / Goals- changes to be achieved / Required treatments & services including patient actions / Arrangements for treatments/ services (What, who) / Review, changes made on Date:
1. Kidney Health Check
eGFR
Current: mL/min/1.73m2 / GP to monitor (every 1 to 3 months)
Urine ACR
Current: mg/mmol / Albuminuria present if urine ACR >3.5 mg/mmol in females and >2.5 mg/mmol in males) / GP to monitor (every 1 to 3 months)
Blood pressure
Current: mmHg / ≤ 140/90 mmHg
or ≤ 130/80 mmHg in people with albuminuria or diabetes / Lifestyle modification
Pharmacological therapy / GP to monitor (every 1 to 3 months)
2. General
Patient’s understanding of chronic kidney disease / Patient to have clear understanding of chronic kidney disease & patient’s role in management the condition / Patient education (list resources, assistance given)
Chronic disease wellness program-Central intake unit ph: 1300 668 936
Adult community health brochures

Use GCUH Renal OPD referral template. / GP/ Nurse
Patient’s understanding of multi-chronic conditions / Patient to have clear understanding of their other chronic condition(s)-
List here: / Patient education (list resources, assistance given) / GP/ Nurse
Patient’s understanding of treatment options for stage 5 CKD (if appropriate) /
  • Patients and their families or carers should receive sufficient information and education regarding the nature of Stage 5 CKD, and the options for the treatment to allow them to make an informed decision about the management of their condition.
  • Treatment choice has more effect on lifestyle than it does on mortality or morbidity.
  • A shared decision making approach is highly recommended.
  • This is best supported by a decision aid, such as the My Kidneys My Choice Decision Aid, available at

Advance Health Directive / Patient education (list resources, assistance given) / GP/ Nurse/ Nephrologist/ Renal Unit Staff
3. Laboratory assessments
Biochemical profile including urea, creatinine and electrolytes / GP/ Nurse (every 1 to 3 months)
Blood glucose (for people with diabetes)
Current: mmol/mol / Generally: ≤53 mmol/mol (range 48-58); ≤7% (range 6.5-7.5).
Needs individualisation according to patient circumstances (e.g., disease duration, life expectancy, important comorbidities, and established vascular complications). / Lifestyle modification
Oral hypoglycaemics
Gliptins
Incretin mimetics
Insulin / GP/ Nurse (every 1 to 3 months)
Lipids
Fasting lipid profile / In adults with newly identified CKD, evaluation with a fasting lipid profile is recommended.
Follow up measurement of lipid levels is not required for the majority of patients / Refer to CKD Management in General Practice (3rd edition) for advice regarding statin therapy
Full blood count / See Anaemia (in Common CKD complications) / GP/ Nurse (every 1 to 3 months)
Calcium and phosphate / See Mineral and bone disorder (in Common CKD complications)
Parathyroid hormone / See Mineral and bone disorder (in Common CKD complications)
4. Other assessments
Absolute Cardiovascular Risk /
CVD disease risk calculator
  • High: greater than 15% risk of cardiovascular disease within next five years
  • Moderate: 10-15% risk of cardiovascular disease within next five years
  • Low: Less than 10% risk of cardiovascular disease within next five years
/ Lifestyle modification
Pharmacological therapy / GP/ Nurse (12 monthly review)
Oedema / GP/ Nurse (every 1 to 3 months)
5. Lifestyle modification
Smoking / Smoking cessation
Quit Line ph: 13 78 48
Clinical guidelines-supporting smoking cessation: a guide for health professionals / Quit (Refer to QUIT Line)
Request a QuitLine call back / Patient to manage
GP to monitor (consider medical therapy)
Nutrition / Consume a varied diet rich in vegetables, fruits, wholegrain cereals, lean meat, poultry, fish, eggs, nuts and seeds, legumes and beans, and low-fat dairy products.
Limit salt to < 6 g salt per day (≤100 mmol/day).
Limit foods containing saturated and trans fats.
See Australian Dietary Guidelines / Patient education (list resources, assistance given)
info
Nutrition Education Materials / GP to monitor
Referral to Accredited Practicing Dietitian for TCA
Healthy GC Dietitian List
Water intake: / See Drink water insteadfrom Kidney Health Australia. / Patient to manage
GP to monitor
Alcohol intake:
Current: / Limit to 2 standard drinks/day
National Health Alcohol Guidelines / Patient education (list resources, assistance given) / Patient to manage
GP to monitor
Physical Activity:
Current: / At least 30 minutes moderate physical activity on most or preferably every day of the week. / Patient exercise routine
(List directions/ instructions given to patient) / Patient to implement
Referral to exercise physiologist for TCA
GCCC health and active site.
Weight
Current:
Waist Circumference
Current:
BMI
Current: / Your targets
Weight: kg
Waist cir: cm
BMI: kg/m2
Ideal weight should be BMI < 25 kg/m2 and waist circumference < 94 cm in men (< 90 cm in Asian men) or < 80 cm in women (including Asian women). / Monitor waist & weight
Review progress 6 monthly
Set new goals 6 monthly
(list resources, assistance given) / Patient to monitor
GP/Nurse to review (12 monthly review)
Referral to exercise physiologist, weight management group
6. Medications
Medication review
Referral for an HMR (item 900)
MBS descriptor of item 900 / Correct use, dosage, compliance of medications to reduce hospital admissions and side effects / Patient Education
Referral to community pharmacist / GP / Pharmacist to review & provide education
Neprotoxic drugs
See page 21 of CKD Management in General Practice / Avoidance
Adjust medication doses to levels appropriate for kidney function (i.e. kidney metabolised/ excreted) / Medication Review / GP / Pharmacist
Vaccinations / Immunisation handbook: 4.7.7: persons at risk of complications from Influenza infection. / Flu shot annually in March/April.
Consider Pneumovax if appropriate. / GP / Nurse
7. Self Management
Self Management / Set achievable goals
Sharing your care with your GP
Ask the right questions
Manage your chronic condition(s) / Self management course
Community chronic disease program

Chronic disease wellness program-Central intake unit ph: 1300 668 936 / Patient to implement
GP/Nurse to review (12 monthly review)
Referral to education/self management group
Support / Kidney Health Information Service
1800 454 363
/ Patient information and education
8. Indications for Nephrologist referral
  • eGFR < 30 mL/min/1.73m2 (Stage 4 or 5 CKD of any cause)
  • Persistent significant albuminuria (urine ACR ≥30 mg/mmol)
  • A sustained decrease in eGFR of 25% or more within 12 months OR a sustained decrease in eGFR of 15 mL/min/1.73m2 per year
  • CKD with hypertension that is hard to get to target despite at least three anti-hypertensive agents
The individual’s wishes and comorbidities should be taken into account when considering referral.
  • Referral Triage Guidelines - Renal
  • GCUH outpatients ph no: 1300 744 267
Recommended tests prior to referral:
  • Current blood chemistry and haematology
  • Urine ACR and urine microscopy for red cell morphology and casts
  • Current and historical blood pressure
  • Urinary tract ultrasound

9. Common CKD complications (more common once eGFR < 30 mL/min/1.73m2) and other conditions
Condition / Target / Management
Acidosis / Supplementation with sodium bicarbonate
Anaemia / Hb 100-115g/L / Refer to CKD Management in General Practice (3rd edition)
Depression /
  • Screen recurrently and maintain a high level of clinical awareness for depression.
  • Modifiable causes of depression should be considered and excluded.
  • Treatment with behavioural and pharmacological therapies
  • Consider K10/DASS
  • ATAPS

Dietary protein / No lower than 0.75g/kg body weight per day / Refer to Accredited Practicing Dietitian
Healthy GC Dietitian List
Haematuria / Use dipsticks rather than urine microscopy as dipsticks are more sensitive and accurate.
Evaluate further if there is a result of 1+ or more.
Do not use urine microscopy to confirm a positive result. However, urine microscopy may be useful in distinguishing glomerular haematuria from other causes.
Hyperkalaemia / K+6.0 mmol/L / Low K+ diet (discuss with an Accredited Practicing Dietitian)
Correct metabolic acidosis (target serum HCO3 > 22 mmol/L)
Potassium wasting diuretics (e.g., thiazides)
Avoid salt substitutes which may be high in K+
Resonium A powder
Cease ACE inhibitor/ARB/spironolactone if K+ persistently > 6.0 mmol/L and not responsive to above therapies
Refer to nearest Emergency Department if K+ > 6.5 mmol/L
Malnutrition / Serum albumin 35g/L / Refer to Accredited Practicing Dietitian
Mineral and bone disorder
Osteoporosis / Keep PO4 in normal range (0.8-1.5 mmol/L)
Keep Ca in normal range (2.2-2.6 mmol/L)
Vitamin D (25-hydroxyvitamin D) levels are adequate if > 50 nmol/L
Refer to Nephrologist if PTH is persistently elevated above the upper limit of normal and rising
Consider BMD / What to measure / GFR 45-59 mL/min/1.73m2 / GFR < 45 mL/min/1.73m2
Calcium & phosphate / 6-12 months / 3-6 months
PTH & alkaline phosphatase* / Baseline / 6-12 months
25-hydroxyvitamin D / Baseline / Baseline
Muscle cramps / Encourage stretching and massaging of the affected area
Tonic water can be effective for frequent cramps
Pruritus /
  • Ensure that there are no other causes for pruritis (e.g., allergies, scabies, inadequate dialysis, calcium/phosphate)
  • Evening Primrose Oil
  • Skin emollients
  • Avoid use of soaps/detergents
  • Topical capsaicin (may not be tolerated because of transient burning feeling on the skin)
  • If both pruritis and restless legs is present, consider gabapentin
  • For persistent pruritis, consider referral to a dermatologist for ultraviolet light B (UVB) therapy

Restless Legs / Check iron status and replace if deficient
Home therapies such as massage, warm baths, warm/cool compresses, relaxation techniques, exercise
Dopaminergic agents or dopamine agonists
Benzodiazepines
Sleep Apnoea / Weight reduction (see page xx lifestyle modification)
Avoid central nervous system depressants (including alcohol)
CPAP therapy (if obstructive pattern)
Uraemia / Dialysis should be commenced as soon as uraemic symptoms develop
Diabetes / Optimal blood glucose control / Monitoring of blood glucose and 3-6 monthly HbA1c test.
Recurrent infection / Early intervention with infection
T.C.A
AHP Type / Reason / Name / No. of EPC visits
5 in total/calendar yr / Agreed to TCA
Yes/No
Summary of Actions Required:
Review Date with GP:
I have explained the steps and any costs involved, and the patient has agreed to proceed with the plan.
<Steps and costs explained, patient agreed>
GP’s Signature: x______Date: <Miscellaneous: Date>
GP Name: <Doctor: Name>
I have agreed / my carer has agreed to this management plan and I understand the recommendations.
Signed by Patient / Carer / or verbal: x______
Date: <Miscellaneous: Date>

Disclaimer: This template was developed from the resource

It has been modified to local needs by GCPHN. It is up to each individual Doctor to ensure compliance with MBS guidelines. It is up to each Doctor to decide best practice care for each individual patient.

Version: February 2016