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Chronic kidney disease Recommend Consider essential screening of ‘at risk’ population groups as kidney disease and failure are often asymptomatic Treat all patients with Type 1 or Type 2 diabetes mellitus complicated by microalbuminuria or overt nephropathy with an ACE inhibitor (ACEI), independent of BP and GFR [1] Related topics: Diabetes, page 332 Hypertension, page 334 Urinary tract infections (adult, child and in pregnancy), pages 278, 410, 592 Acute post streptococcal glomerulonephritis, page 537 1. May present with: Diagnosis of chronic kidney disease 2. Immediate management: not applicable 3. Clinical assessment: The assessment process includes: Take complete patient history including medication history family history of diabetes, kidney disease or other risk factors Perform standard clinical observations + weight, height venous BGL and FBC, fasting cholesterol / triglycerides / LDL / HDL, serum creatinine, urinalysis for protein and blood, followed by urine collection for albumin creatine ration (ACR) and MCS if applicable Physical examination Assess absolute cardiac risk Assess absolute cardiac risk - Absolute cardiovascular disease risk assessment available at National Heart Foundation of Australia 2009 http://www.heartfoundation.org.au/SiteCollectionDocuments/A_AR_QRG_FINAL%20FOR%20WEB .pdf 4. Management: BP control is the most important measure in slowing kidney disease progression - aim for BP< 125/75. The rate of kidney function decline is accelerated by hypertension [3] Treat underlying cause and prevent or slow progression Stress that symptoms are generally uncommon and consequences of kidney disease occur many years in the future MO may advise initiation or re-supply of medications: Antihypertensives - angiotension converting enzyme inhibitors (ACEI’s) are the mainstay of treatment, associated with a reduction in proteinuria and slowing of the rate of progression to renal failure [1] Combination of ACEI’s and angiotensin receptor blockers (ARB) may be more effective than a single agent [4] Statin therapy should be prescribed for all people with diabetes [5] Metformin should not be used if creatinine is increased or GFR is decreased [3] Correct anaemia with erythropoietin Oral alkali replacement maybe required to manage acidosis Phosphate binder (calcium carbonate) and vitamin D metabolite (calcitriol) may be required to manage parathyroid hormone levels. Schedule 4 Renal drugs Authorised Indigenous Health Workers must consult MO and supply under the conditions of the DTP Nurse Practitioners may proceed Route of Form Strength Recommended Dosage Administration Tablet As ordered by MO Oral As ordered by MO Vitamin D metabolite Diuretic Phosphate binder Calcitriol Frusemide Caltrate Hydrochlorothizide Titralac Indapanide Aluminium hydroxide (Alutabs) Management of Associated Emergency: Consult MO 5. DTPIHW / NP Duration As ordered by MO Follow up: According to Queensland Health current edition Chronic Disease Guidelines or local protocols if outside Queensland 6. Referral / Consultation: According to Queensland Health current edition Chronic Disease Guidelines or local protocols if outside Queensland