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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
General Practitioner’s Details
Doctor Name:
Patient’s Name:
Sex:
Male Female
DOB:
Address:
Medicare No:
Carer’s Details (if appropriate)
Practice:
Address:
Provider No:
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>>
Disclaimer: This template was developed from the resource
www.kidney.org.au. 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
Patient needs/
Goals- changes to be achieved
relevant conditions
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
Urine ACR
Current:
mg/mmol
GP to monitor
(every 1 to 3
months)
Albuminuria present if urine ACR >3.5
mg/mmol in females and >2.5 mg/mmol in
males)
≤ 140/90 mmHg
Blood pressure
Current:
mmHg or ≤ 130/80 mmHg in people with
albuminuria or diabetes
GP to monitor
(every 1 to 3
months)
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
GP/ Nurse
resources, assistance given)
Chronic disease wellness
program-Central intake unit
ph: 1300 668 936
Adult community health
brochures
http://www.kidney.org.au/
Use GCUH Renal OPD referral
template.
Patient’s
understanding of
multi-chronic
conditions
Patient to have clear understanding of their Patient education (list
other chronic condition(s)resources, assistance given)
List here:
 Patients and their families or carers
Patient’s
Patient education (list
should receive sufficient information and resources, assistance given)
understanding of
education regarding the nature of Stage 5
treatment options
CKD, and the options for the treatment to
for stage 5 CKD (if
allow them to make an informed decision
appropriate)
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
http://homedialysis.org.au/choosing/mydecision/
Advance Health Directive
GP/ Nurse
GP/ Nurse/
Nephrologist/ Renal
Unit Staff
3. Laboratory assessments
Biochemical profile
including urea,
GP/ Nurse (every 1
Disclaimer: This template was developed from the resource
www.kidney.org.au. 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
creatinine and
electrolytes
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
Lipids
Fasting lipid profile
 In adults with newly identified CKD,
Refer to CKD Management in
General Practice (3rd edition)
for advice regarding statin
therapy
Full blood count
evaluation with a fasting lipid profile is
recommended.
 Follow up measurement of lipid levels is
not required for the majority of patients
See Anaemia (in Common CKD
complications)
Calcium and
phosphate
See Mineral and bone disorder (in Common
CKD complications)
Parathyroid
hormone
See Mineral and bone disorder (in Common
CKD complications)
GP/ Nurse (every 1
to 3 months)
GP/ Nurse (every 1
to 3 months)
4. Other assessments
Absolute
www.cvdcheck.org.au
Cardiovascular Risk CVD disease risk calculator
Lifestyle modification
Pharmacological therapy
GP/ Nurse (12
monthly review)
 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
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)
http://www.kidney.org.aupatient info
Nutrition Education Materials
GP to monitor
Referral to
Accredited
Practicing Dietitian
for TCA
Healthy GC Dietitian
List
Water intake:
See Drink water instead from Kidney Health
Australia.
Alcohol intake:
Limit to < 2 standard drinks/day
Patient to manage
GP to monitor
Patient education (list
Patient to manage
Disclaimer: This template was developed from the resource
www.kidney.org.au. 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
Current:
National Health Alcohol Guidelines
resources, assistance given)
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:
Your targets
Weight: kg
Waist cir: cm
BMI:
kg/m2
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
Medication review Correct use, dosage, compliance of
medications to reduce hospital admissions
Referral for an
and side effects
HMR (item 900)
MBS descriptor of
item 900
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
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
http://www.kidney.org.au/
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
www.kidney.org.au
Patient information and
education
Waist
Circumference
Current:
BMI
Current:
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).
6. Medications
7. Self Management
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
Disclaimer: This template was developed from the resource
www.kidney.org.au. 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
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/1.73m 2) and other conditions
Condition
Target
Acidosis
Anaemia
Supplementation with sodium bicarbonate
Hb 100-115g/L
Refer to CKD Management in General Practice (3rd edition)
No lower than 0.75g/kg body weight
per day
 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
Refer to Accredited Practicing Dietitian
Healthy GC Dietitian List
Depression
Dietary protein
Management
 Use dipsticks rather than urine microscopy as dipsticks are more
Haematuria


Hyperkalaemia
Malnutrition
Mineral and bone
disorder
Osteoporosis
Muscle cramps
K+<6.0 mmol/L
Serum albumin >35g/L
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
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.
 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
Refer to Accredited Practicing Dietitian
What to
measure
Calcium &
phosphate
PTH & alkaline
phosphatase*
25hydroxyvitamin D
GFR 45-59
mL/min/1.73m2
6-12 months
GFR < 45
mL/min/1.73m2
3-6 months
Baseline
6-12 months
Baseline
Baseline
Consider BMD
 Encourage stretching and massaging of the affected area
 Tonic water can be effective for frequent cramps
Disclaimer: This template was developed from the resource
www.kidney.org.au. 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
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
 Weight reduction (see page xx lifestyle modification)
 Avoid central nervous system depressants (including alcohol)
 CPAP therapy (if obstructive pattern)
 Dialysis should be commenced as soon as uraemic symptoms
Sleep Apnoea
Uraemia
develop
Diabetes
 Monitoring of blood glucose and 3-6 monthly HbA1c test.
 Early intervention with infection
Optimal blood glucose control
Recurrent 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
www.kidney.org.au. 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