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Algorithm Description

KidneyWise

This App, created by the Ontario Renal Network, follows a new evidence-based clinical algorithm that is designed to help primary care providers with identification, detection and management of chronic kidney disease (CKD) and guide on which patients may benefit from referral to nephrology.

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Evaluate Risk of CKD

My patient has one or more of the below CKD risk factors:
  • Hypertension
  • Diabetes mellitus
  • Age 60-75 with cardiovascular disease

Indicate whether a risk factor is present by selecting Yes or No.

CKD testing not required.

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Confirm CKD Diagnosis (results after 3 months)

Indicate eGFR and urine ACR results to confirm diagnosis.

Note: an eGFR and an urine ACR value are required.

Select eGFR result
Select urine ACR result

Select test result values to confirm diagnosis.

Your patient has CKD.

Note: at least 2 out of 3 random urine ACRs must be elevated within 3 months, in order to be considered abnormal to confirm the presence of CKD.

Your patient has CKD. He/she can be followed in primary care.

Note: at least 2 out of 3 random urine ACRs must be elevated within 3 months, in order to be considered abnormal to confirm the presence of CKD.

Patient does not have CKD.

Note: at least 2 out of 3 random urine ACRs must be elevated within 3 months, in order to be considered abnormal to confirm the presence of CKD.

When should I follow-up with my patient?

Select urine ACR result to confirm diagnosis

Select eGFR result to confirm diagnosis

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Diagnosis Actions

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Follow-up

Patient Follow-up Recommendations:

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Managed CKD Follow-up

Patient Follow Up Recommendations:

Follow eGFR and urine ACR every six months.

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Monitor CKD Patient in
Primary Care

Since the patient's last visit, are any of the following true?

Select whether any of the above conditions are true or false by selecting Yes or No.

Has your patient's eGFR been stable for 2 years?

Select Yes or No above to determine the frequency of patient follow-up

Follow eGFR & urine ACR every 12 months.

Please re-enter KidneyWise App in 12 months at Monitor CKD Patient.

Follow eGFR & urine ACR every 6 months.

Please re-enter KidneyWise App in 6 months at Monitor CKD Patient.

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Monitor CKD Patient in
Primary Care

Since the patient's last visit, are any of the following true?

Select whether any of the above conditions are true or false by selecting Yes or No.

Has your patient's eGFR been stable for 2 years?

Select Yes or No above to determine the frequency of patient follow-up

Follow eGFR & urine ACR every 12 months.

Please re-enter KidneyWise App in 12 months at Monitor CKD Patient.

Follow eGFR & urine ACR every 6 months.

Please re-enter KidneyWise App in 6 months at Monitor CKD Patient.

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CKD Management

Recommended Management Interventions:

Implement measures to modify CV risk factors

  • Lifestyle modification, smoking cessation
  • Lipid management for patients with CKD (see KDIGO guidelines):
    • If with diabetes, age > 18 treat with a statin*
    • If without diabetes, age ≥ 50 treat with a statin*
    • If without diabetes, age 18–49, has known coronary artery disease, prior stroke, or 10 year Framingham risk > 10% treat with a statin*
  • For patients with diabetes, target HbA1c to appropriate level (see CDA guidelines)

*Contraindications: active liver disease, high alcohol consumption or pregnancy. Women with childbearing potential should only use statin if there is reliable contraception.

Minimize further kidney injury

  • If possible, avoid nephrotoxins such as NSAIDs, IV and intra-arterial contrast etc. (if eGFR < 60)
  • If contrast is necessary, consider oral hydration, withholding diuretics
  • Refer to Sick Day Medication List (see Evidence Summary)

Implement measures to slow rate of CKD progression

BP and RAAS blockade (repeat creatinine and potassium 2 weeks after initiation of ACEI or ARB) use:

  • If with diabetes, target BP < 130/80, otherwise target BP < 140/90
  • If with diabetes with ACR > 3, start an ACEI or ARB as first-line therapy. If BP already < 130/80, use ACEI or ARB cautiously, monitoring for signs and symptoms of hypotension
  • If without diabetes, ACR > 30 and BP > 140/90, start use of a ACEI or ARB as first-line therapy
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CKD Management

Recommended Management Interventions:

Implement measures to modify CV risk factors

  • Lifestyle modification, smoking cessation
  • Lipid management for patients with CKD (see KDIGO guidelines):
    • If with diabetes, age > 18 treat with a statin*
    • If without diabetes, age ≥ 50 treat with a statin*
    • If without diabetes, age 18–49, has known coronary artery disease, prior stroke, or 10 year Framingham risk > 10% treat with a statin*
  • For patients with diabetes, target HbA1c to appropriate level (see CDA guidelines)

*Contraindications: active liver disease, high alcohol consumption or pregnancy. Women with childbearing potential should only use statin if there is reliable contraception.

Minimize further kidney injury

  • If possible, avoid nephrotoxins such as NSAIDs, IV and intra-arterial contrast etc. (if eGFR < 60)
  • If contrast is necessary, consider oral hydration, withholding diuretics
  • Refer to Sick Day Medication List (see Evidence Summary)

Implement measures to slow rate of CKD progression

BP and RAAS blockade (repeat creatinine and potassium 2 weeks after initiation of ACEI or ARB) use:

  • If with diabetes, target BP < 130/80, otherwise target BP < 140/90
  • If with diabetes with ACR > 3, start an ACEI or ARB as first-line therapy. If BP already < 130/80, use ACEI or ARB cautiously, monitoring for signs and symptoms of hypotension
  • If without diabetes, ACR > 30 and BP > 140/90, start use of an ACEI or ARB as first-line therapy
Step 3: Monitor your patient
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Managed CKD Referral

logic for referral of managed CKD patient

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Work-up

Recommended Work-up:

For low eGFR: urine R+M, CBC, electrolytes, Ca, PO4, Albumin, PTH

For Albuminuria: urine R+M, electrolytes

Refer to a nephrologist
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Acceptance of Terms and Conditions and Changes

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Disclaimer

The information contained in and/or accessed through this website or mobile application, as applicable (the "Content") is intended to be for informational purposes only. The Content was created by the Ontario Renal Network ("ORN"), a work unit within Cancer Care Ontario ("CCO"). The Content is intended for healthcare providers. It is not intended to constitute or be a substitute for medical advice and should not be relied upon in any such regard. Furthermore, use of the Content is subject to professional and clinical judgment given by a qualified physician or other qualified healthcare professional. Links to other applications or websites are also for informational purposes only and are not endorsed by CCO. Anyone accessing, reviewing or using the Content does so at his or her own risk.

While care has been taken in the preparation of the information contained in the Content, such information is provided on an "as-is" basis, without any representation, warranty, or condition, whether express or implied, statutory or otherwise, as to the information's quality, accuracy, currency, completeness, or reliability. CCO and any content providers (including, without limitation, any physicians who contributed to the information in the Content) shall have no liability, whether direct, indirect, consequential, contingent, special, or incidental, related to or arising from the Content or its use thereof. The Content may not reflect all the available scientific research and is not intended to be an exhaustive resource. The Content is subject to change, revision or restatement from time to time, without prior notice to you.

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