CKD in Primary Care - MSHP - Mount Sinai Health Partners

Managing CKD in your primary care practice? Find resources to help you. Follow this handy checklist to ensure you complete your screenings and meet clinical targets, review diagnosis and staging criteria as well as common medications in CKD, gain confidence in managing complications and comorbidities, and know when to refer to a specialist.

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Checklist for CKD Management for Frontline Providers

Screening/Management	Clinical Targets	Frequency of Testing/Visits	Next Steps for Uncontrolled/Positive Finding
Estimate GFR and Albuminuria	GFR >=90 Urine ACR <30 mg/g	Stages 1-2: Annually Stage 3: Semiannual Stages 4/5: Quarterly	Determine if progressive Estimate risk for progression (Kidney Failure Risk Equation or KidneyIntelX in diabetics)
Nutrition	Protein Intake Stage 5: 0.6-0.8 g/kg/d Sodium intake Stages 3/4-5: <4g/3 g/d Stages 3-5 w Htn: <2 g/d	Annually and as needed	Provide dietary counseling (Nutritionist or CDE) Protein composition recommended: 50% High Biologic Value and 50% plant-based
Blood Pressure Control	Target Blood Pressure: <130/80	Monthly until controlled, then every 3-6 months	Lifestyle modification, Home BP monitoring Non-Diabetic: ACR <30 mg/g, GFR <60: Use ACE/ARB, CCB, Diuretic ACR 30-299 mg/g: Use of ACE/ARB suggested ACR >300 mg/d: Use ACE/ARB Diabetic: ACR<30: Use ACE/ARB, CCB, and/or Diuretic ACR >30 or GFR<60: Use ACE/ARBR
Diabetes Mellitus Management	HbA1c <7% (range <6.5-8%) Urine ACR <30 mg/g	Controlled: q 6 mon Poorly controlled: q 3 mon	Intensify medications to optimize control With CKD, both metformin and SGLT-2i as first line therapy Use GLP-1 RA if intolerant to SGLT-2i or GFR <30
Lipid Management	LDL <130 or <100 based on ASCVD risk	Annually	Lifestyle modification Statin therapy for Stage 3-5 (Non-Dialysis)
Metabolic Acidosis	Sodium Bicarbonate >22 meq/l	Stage 1-2: Annual Stage 3: q 6 mon Stages 4/5: q 3 mon	If bicarbonate <22 mEq/l, add sodium bicarbonate (650 mg TID) or sodium citrate (30 ml/d
Anemia	Hgb level >13 mg/dl men, >12 women	Stage 3: Annual Stages 4-5:q 3 mon On ESA : q 3 mon	Replete iron orally or IV if iron deficient (FeS04 325 mg TID, Fe gluconate 2-3 mg/kg/d BID-TID) Erythropoiesis Stimulating Agents if refractory
Bone Metabolic Disease	Normal Calcium and Phopshate concentrations	Screening at GFR <5 Stage 3B: q 6-12mon Stage 4: q 3-6 mon Stage 5: q 1-3 mon	Correct hypocalcemia if <7.5 mg/dl (adjust-ed for albumen), symptomatic, or severe hyperPTH Treat hyperphosphatemia with diet (~900 mg/d) and phosphate binders if >6 mg/dl
	Vitamin D	Screening to establish baseline and as needed	Correct as without CKD, if Phosp/calcium normal. Calcitriol or synthetic vitamin D analogs if progressive hyperparathyroidism
	Parathyroid hormone level	Stage 3B: Baseline Stage 4: q 6-12 monStage 5: q 3-6 mon	Correct modifiable factors Calcitriol/Vit D analogues for severe progressive disease
Hyperkalemia	Serum Potassium	Stage 1-2: Annual Stage 3: q 6 mon Stages 4/5: q 3 mon	Low potassium diet Reduce or eliminate contributing meds Correct acidosis Sodium polystyrene, Patiromer, or Sodium zirconium cyclosilicate
Behavioral Health	Depression Screen: PHQ 2/9	Annual Screening	Confirm diagnosis of depression Initiate treatment and/or refer
Immunizations	PPSV23 Hepatitis B Influenza	1x if GFR <30 or higher risk, repeat in 5y. Complete Hep B series when GFR <30 and at risk of progression. Annual influenza vaccination.	Consider administration of PV 13 at 65yrs Check HepBs Ab to confirm immunity

Diagnosis & Staging

History: majority of cases are asymptomatic and detected incidentally or through screening

• Chronic kidney disease is defined as any abnormality of kidney function or structure lasting at least 90 days

• CKD should be distinguished from acute kidney injury (2-7 days) and acute kidney disease (<3 months)

Diagnostic Testing

• Estimate GFR using serum creatinine, age, gender (typically on lab report, do not adjust by race)

• Measure urinary albumin excretion: urine albumin to creatine ratio (ACR) preferred test

• NOTE: In Epic, “Kidney Profile” order includes eGFR, urine albumin, and urine creatinine.

• Renal ultrasound typically obtained to assess kidney structure and rule out obstruction.

Classification - focus on GFR AND level of albuminuria

• Stratify GFR into Stages 1-5, urine ACR into stages A1-A3

• Use table below to classify risk of progression, monitoring frequency, and time interventions

• Progression defined as drop in GFR category and a 25% decrease from GFR baseline

• Rapid progression is a decline in GFR of = 5 ml/min/1.73m2 per year

• If GFR <60, use Kidney Failure Risk Equation to estimate 2 yr and 5 yr of dialysis or renal transplantion (https://kidneyfailurerisk.com/) or KidneyIntelX for diabetic

Diet & Lifestyle

Component	CKD Status	Recommendation
Protein	Stage 5 (Possibly Stages 3b-4)	Consider 0.6-0.8 g/kg/d protein (50% high biologic value, 50% plant based) (70 kg pt =70g, ¼ pound of beef or cheese has 28 g protein, ½ cup grain has 3 g)
Salt	Stage 3-5	<4 g/d Stage 3, or <;3 g/d for Stage 4-5, symptomatic fluid retention/proteinuria, <2g/d if hypertensive or diabet-ic (1/4 teaspoon salt has 575 g sodium)
Potassium	Stage 3	<4.7 grams per day (442 mg per banana, 230 mg in ¼ cup orange juice)
Potassium	Stage 4-5	<3 grams per day
Calcium	Stage 3-5 (Pre-dialysis)	800-1,000 mg daily (1 calcium carbonate tablet has 500-600 mg elemental Ca)
Fluids	Stage 3	Restrict to <1.5 liters per day (approximately six 8 oz glasses of water)
Energy	All	30-35 kcal/kg per day
Exercise	All	30 minutes a day, five days a week

Delaying Disease Progression

Hypertension

See table

Diabetes Mellitus

See table

Screening

Annual urine ACR and GFR estimation, start 5 yrs after dx of DM1, upon dx of DM2

Type 2 DM Treatment Recommendations (see table)

Target HbA1c: Range 6.5%-8% depending on comorbidities, life expectancy, CKD severity
Use SGLT-2 inhibitor with metformin if GFR >30, and UACR >30 mg/g, particularly if UACR >300 mg/g
Use GLP-2 RA if SGLT-2i contraindicated (GFR <30), not tolerated or 3rd antihyperglycemic needed

Managing Complications

Metabolic Acidsosis (See Table)

If HC03 <22 mEq/l: treat with oral bicarbonate to normalize level

Hyperkalemia (See Table)

Severe (K> 6.0—6.5 mEq/l): clinical emergency mandating immediate care

Iron Deficiency Anemia

Iron supplementation useful in both absolute and functional iron deficiency

Bone Mineral Disorder

Hypocalcemia: Supplement calcium if severe, progressive secondary hyperparathyroidism, not if mild
Vitamin D Deficiency
- Calcitriol use limited to progressive hyperparathyroidism (PTH levels 2.5-3X upper limit of nml)
- Calcitriol 0.25 mg three times a week, if corrected Ca <9.5 and normal phosphate
- Non-calcium containing binders
- Other synthetic vitamin D agents

Managing Common Comorbidities

Cardiovascular Disease

Coronary Artery Disease: Antiplatelet Therapy

• Primary Prevention: ASA/other antiplatelet agents may be modestly useful

• Secondary Prevention: Low dose ASA (81 mg) is preferred to higher doses

Heart Failure

• SGLT-2 inhibitors have beneficial effects on HF and CKD, with and without DM

Lipid Disorders

• Treatment recommendations for patients 40-75 years old

• Patients with GFR 15-60 and/or urine ACR >30 mg/g not receiving dialysis or post-transplant with 10 yr ASVCD risk >7.5% should be treated with a statin +/- ezetimbi

• GFR >60 and albuminuria or other kidney disease, should receive a statin or have treatment reserved for those with increased ASCVD risk

• Moderate intensity statin doses recommended (e.g. Atorvastatin 40 mg/d), unless other indications for high dose. Doses of renally excreted statins may need to be reduced.

Clinical Integration Care Delivery Steps

Nephrology Referral Indications

• Clarify cause of CKD and/or assistance managing related complications, AKI or abrupt sustained fall in GFR.

• All Stage 4-5 CKD (GFR <30), urine ACR >300 mg/g, KidneyIntelXTM medium or high risk score

• Resistent hypertension, persistent hyper-/hypokalemia, hyperphosphatemia, anemia warranting ESA

• Planning for or initiation of dialysis (if risk of kidney failure within next year is >10-20%) • Transplantation: Should be considered if GFR <20 with likely progressive, irreversible CKD over next 6-12 months

Find a nephrologist

Care Management Referral Indications

• Multiple no-shows, treatment non-adherence• Demonstrated difficulty managing symptoms and/or disease processes

• Frequent potentially preventable admissions or ED visits

• Complex family dynamics, difficulty accessing needed community-based care, and/or a high “worry score”

Use MSHP Care Management Referral in Epic, email mshpcmreferral@mountsinai.org, or call 212-241-7228

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References

1. Chen TK, Knicely DH, Grams ME, Chronic Kidney Disease Diagnosis and Man-agement: A Review. JAMA. 2019 October 01; 322(13): 1294–1304

2. KDIGO 2020 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease Kidney International Supplements 2020;98:1-120

3. KDIGO 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease–Mineral and Bone Disorder (CKD-MBD) Kidney International Supplements, 2017;7:1-

Chronic Kidney Disease Quick Guide