Managing Patients with Kidney Diseases

Referral Criteria and Care Coordination

The American Journal of Kidney Diseases recommends referring patients to specialist kidney care services when eGFR <30 mL/min/1.73 m² (CKD stages G4-G5), as these patients benefit most from nephrology expertise 1, 2
Consider referral for patients with persistent proteinuria >1 g/day (ACR ≥60 mg/mmol or PCR ≥100 mg/mmol), as these patients may require renal biopsy and potential immunosuppressive therapy 1, 2
Implement risk prediction models to optimize triage of patients at high risk of kidney failure to specialty care for shared or subsequent care 3, 4
Refer patients with abrupt sustained decrease in eGFR >20% after excluding reversible causes, or if features suggest diagnosis other than prerenal azotemia or acute tubular necrosis 1
Consider collaborative care approaches between primary care and nephrology for early CKD stages to mitigate disease progression upstream 4, 5

Incorporate regular symptom screening into clinical practice, focusing on symptoms most important to patients, as recommended by Kidney International 6, 7
Use open-ended questions to facilitate dialogue: "How are you feeling?", "What is bothering you most?", "Has anything changed?" 6, 7
Acknowledge symptoms even when treatment options are limited, as feeling heard and understood is therapeutic for patients with life-limiting illness 6, 7
Ensure symptom assessment takes into consideration biological, psychological, and social factors surrounding the patient 6, 7

Implement lifestyle modifications as a cornerstone of CKD management, including smoking cessation, regular exercise, and healthy diet (fruits, vegetables, legumes, whole grains), as recommended by Kidney International 8
Accurately diagnose and stage CKD to guide treatment choices, medication dosing, and nephrotoxin avoidance 8
Use ACE inhibitors/ARBs as first-line agents in those with albuminuria, even in the absence of hypertension 8

Consider nontraditional modes of nephrology care delivery such as e-consults and telenephrology to improve access to specialty care 4
Utilize interactive educational interventions that include both individual and group participation to improve knowledge and self-management for secondary prevention of CKD 8
Address barriers to patient education including inappropriate literacy levels, poor access to multidisciplinary teams, or lack of health system preparedness 8

Avoid labeling patients with isolated low eGFR (especially G3a) without associated markers of kidney damage as having CKD, as this can cause insurance problems, according to the American Journal of Kidney Diseases 9
Recognize that the vast majority of patients with stage 3 CKD do not progress to ESRD but die mainly from cardiovascular causes; primary care intervention for cardiovascular risk reduction should be strongly considered 1
Remember that medication dosing requires careful consideration in CKD patients to avoid toxicity, particularly with gabapentinoids and baclofen which can cause sedation and encephalopathy in advanced CKD 8

The KDIGO guidelines emphasize that multidisciplinary care teams enhance outcomes for patients with complex CKD, particularly when multiple comorbidities are present, as seen in patients with stage 3a CKD and cardiac and immune complications 10, 11

The 2023 KDIGO Controversies Conference concluded that multidisciplinary care benefits are greatest for patients with advanced CKD and complex comorbidity, with a comprehensive care model resulting in fewer hospitalized days, lower resource utilization, and higher quality of life compared to usual care, as demonstrated by the Canadian Prevention of Renal and Cardiovascular Endpoints Trial 12, 13
The KDIGO guidelines recommend a multidisciplinary team approach for patients with CKD and multiple comorbidities, including nephrology, cardiology, primary care, clinical pharmacy, dietitian, and infectious disease or immunology consultation, to optimize outcomes and prevent rapid deterioration 12, 13

The American Journal of Kidney Diseases recommends that patients with CKD and immunocompromise receive aggressive vaccination, including annual influenza vaccination, pneumococcal vaccination, and hepatitis B vaccination, to prevent infection-related mortality 14
The KDIGO guidelines suggest that clinical pharmacists play a critical role in medication reconciliation and dose adjustments in renal dysfunction, to avoid toxicity and optimize outcomes 12

The KDIGO guidelines recommend establishing a lead coordinator to ensure regular multidisciplinary case conferences, unified medication lists, coordinated monitoring schedules, and clear care pathways for acute decompensation, to empower patients through education and prioritize their concerns and preferences 11, 12