online clinical pathway for chronic kidney disease (ckd) in primary
TRANSCRIPT
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September 10th, 2016 Maoliosa (Mo) Donald University of Calgary
Online clinical pathway for chronic kidney disease (CKD) in primary
care
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Presenter Disclosure
•Presenter’s Name: Maoliosa Donald
• I have no current or past relationships with commercial entities
•Speaking Fees for current program: I have received no speaker’s fee for this learning activity
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Commercial Support Disclosure
This program has received no financial or in-kind support from any commercial or other organization.
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Personal Disclosure….
• Not a pharmacist
• Related to a retired pharmacist
So why am I here???
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Outline
• Background • Diagnosis, medical management and referral • Experience the online CKD clinical pathway • Preliminary evaluation of uptake
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Background
The majority of patients with CKD in Alberta are cared for by primary care providers:
Manns BJ, et al. A cluster randomized trial of an enhanced eGFR prompt in chronic kidney disease. Clin J Am Soc Nephrol, 2012;7:565-572.
95%
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Background
Severe renal insufficiency
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Background
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But . . .
“Nearly two-third (62%) of publications cited to support primary care recommendations were of uncertain relevance to patients in primary care.”
National Institute for Health and Care Excellence (NICE) Guidelines
J Clin Epidemiol. Nov 2014; 67(11): 1251–1257
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Background
Why a clinical pathway?
•Coordination & continuity of
care enhanced
•Increase clinic efficiency
•Improve patient safety
•Increase team function
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Components of the clinical pathway
•Diagnosis of CKD (who and how to test)
•Management of patients with CKD
•Referral
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Background
Pathway Characteristics
Practical
Integrate into clinical
care
Feasible
Target primary care
setting
Harmonize with other Canadian
CPGs
Enhance patient care
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Worked closely with our pharmacy colleagues
Craig
Carlee
Background
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Background
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Who to test?
Targeted for individuals of increased risk of CKD:
• Hypertension
• Diabetes Mellitus
• Family hx of Stage 5 CKD or hereditary kidney dz
• Vascular disease (CVD, stroke/TIA or PVD)
• Multisystem disease with potential kidney
involvement (SLE)
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Recommended tests
•eGFR (estimate glomerular filtration rate)
•Urine: Random Urine ACR (albumin:creatinine
ratio) Urinalysis for hematuria
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How to test?
•Repeat eGFR, random urine ACR (albumin:creatinine ratio) and urinalysis if not tested in the prior 6 months
•A new finding of reduced eGFR may be due to
reversible causes (e.g. acute kidney injury, or initiation of ACEi/ARB therapy)
• If previous finding of abnormal eGFR and ACR in the past 6 months, you do not have re-test
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How frequent to test?
•eGFR (estimate glomerular filtration rate)
•Random Urine ACR (albumin:creatinine ratio)
•Urinalysis for hematuria
•Every year for hypertension and diabetes
•Every 2 years for all others
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How to diagnose CKD?
Either of the following present for >3 months:
•Markers of kidney damage:
Albuminuria ( ACR ≥3 mg/mmol)
OR
•Decreased eGFR: eGFR <60 mL/min/1.73 m2
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What eGFR constitutes a diagnosis of CKD?
eGFR category eGFR (mL/min/1.73 m2) Description
G1 >90 Normal or high
G2 60-89 Mildly decreased
G3a 45–59 Mildly to moderately decreased (CKD)
G3b 30–44 Moderately to severely decreased (CKD)
G4 15–29 Severely decreased (CKD)
G5 <15 Kidney failure (CKD)
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How is ACR categorized?
* Note that where albuminuria measurement is not available, urine reagent strip results can be substituted
Category
ACR (Approximate equivalent)
(mg/mmol)
Terms
A1 <3 Normal to mildly increased
A2
3-30 Moderately increased
A3
>30 Severely increased
Abbreviations: ACR, albumin:creatinine ratio
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Where can I find more detailed information?
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Case: Helen 68 year old retired teacher
Medications: •HCTZ 12.5 mg od •Amlodipine 5 mg od •Metformin 500 mg TID
BP: 149/84 mmHG
PMHX: •Type 2 DM •Hypertension •Anxiety •OA •Dyslipidemia
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Diagnosis
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Diagnose
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Case: Helen 68 year old retired teacher
Labs:
• eGFR = 42 ml/min/1.73m2
• ACR = 38 mg/mmol
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Diagnose
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Medical Management
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Medical Management
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Case: Helen 68 year old retired teacher
•Meds: •HCTZ 12.5 mg od •Amlodipine 5 mg od •Metformin 500 mg TID
•BP: 149/84 mmHG
•PMHX:
• Type 2 DM
•Hypertension
•Anxiety
•OA
•Dyslipidemia
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Medical Management
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Medical Management
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Medical Management
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Medical Management
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Medical Management
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Case: Helen 68 year old retired teacher
• Ramipril 5 mg daily started
• Potassium increase from
4.9 mmol/L to 5.2 mmol/L
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Medical Management
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Case: Helen – 1 year later 69 year old retired teacher
Labs:
• eGFR = 46 ml/min/1.73m2
• ACR = 70 mg/mmol
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Referral
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Referral
http://departmentofmedicine.com/mas/documents/mas_form_interactive.pdf
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Referral
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Referral
Elements of a good referral:
Clinical question (what do you want)
Past medical history
Medication list
Serial creatinine measurements
Urinalysis
Quantification of albuminuria
Ultrasound only if clinically indicated
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Referral
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•PMHX:
•Hypertension
•OA
Case: Mark 48 year old mechanic
•Meds: •HCTZ 12.5 mg od • Ibuprofen
•BP – 125/80 mmHG
•eGFR 45
•ACR 2 mg/mmol
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Medical Management
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Medical Management
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•PMHX:
•Hypertension
•OA
Case: Mark 48 year old mechanic
•Meds: • HCTZ 12.5 mg od
• Ibuprofen
• BP – 125/80 mmHG
• eGFR 45
• ACR 2 mg/mmol
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3 Key Messages
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1. Who should be tested?
• Hypertension • Diabetes Mellitus • Family history Stage 5 CKD or hereditary kidney diagnosis • Vascular disease (CVD, stroke/TIA or PVD) • Multisystem disease with potential kidney involvement (SLE)
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2. What tests should be ordered?
• eGFR to assess kidney function • Random urine ACR to assess for significant
persistent albuminuria • Urinalysis to assess hematuria
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3. What do you do with the results?
Go to www.ckdpathway.ca to determine medical management and referral.
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Other resources
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Acknowledgements
• Primary care physicians, nurses, pharmacists,
nephrologists and dieticians
• Financial support from: • CIHR • AI-HS • Northern and Southern Alberta Renal Programs
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www.ckdpathway.ca
www.ckdpathway.ca