CHRONIC KIDNEY DISEASE MANAGEMENT PLAN  –   721                     REVIEW – 725   
 <Practice>  Phone: <UsrPhone>    Fax:  <UsrFax> 	

Patient Details
 <PtDetails>	GP Details:
 <DrDetails>	Patient agreement for the GP Management Plan proceed
My GP has explained the steps & costs of the GP Management Plan & I agree to proceed.                                                                                  Yes            

Where I am referred to other service providers as listed on this GP Management Plan, I consent to my GP sharing  relevant information about myself to that provider. I have advised my GP of any information I wish to be withheld.
                                                                                                Yes    
I understand that  <Practice>  has one health record for patients and that this record is shared by  all  <Practice>   health team providers          Yes    	

Chronic Kidney Disease (CKD)
Chronic kidney disease occurs when one suffers from gradual and usually permanent loss of kidney function over time. This happens gradually, usually months to years. With loss of kidney function, there is an accumulation of water; waste; and toxic substances, in the body, that are normally excreted by the kidney. Loss of kidney function also causes other problems such as anemia, high blood pressure, acidosis (excessive acidity of body fluids), disorders of cholesterol and fatty acids, and bone disease. Chronic kidney disease is divided into five stages of increasing severity. These stages are measured using a test called Glomerular filtration rate (GFR): The GFR is a standard means of expressing overall kidney function. As kidney disease progresses, GFR falls. The normal GFR is about 100-140 mL/min in men and 85-115 mL/min in women. It decreases in most people with age.	
MY STAGE OF KIDNEY DISEASE	
eGFR mL/min/1.73m2 = 90  Stage 1 CKD – kidney damage with normal kidney function
eGFR mL/min/1.73m2 = 60-89  Stage 2 CKD – kidney damage* with mild kidney function
eGFR mL/min/1.73m2 = 30-59  Stage 3 CKD – moderate  kidney function
eGFR mL/min/1.73m2 = 15-29  Stage 4 CKD – severe kidney function
eGFR mL/min/1.73m2 = <15        Stage 5 CKD – end-stage kidney disease
Based on the stage of kidney disease above please delete the rows below that are not relevant to this patient	

Goals of Stage 1–2 CKD management

– investigations to exclude treatable kidney disease
– reduce progression of kidney disease
– reduce cardiovascular risk	Monitoring in Stage 1–2 CKD

•	3–6 monthly clinical review
•	clinical assessment
•	blood pressure(< 130/80 mmHg < 125/75 mmHg if proteinuria > 1g/24hrs)
•	weight
•	urine dipstick
•	laboratory assessment
•	biochemical profile including urea, creatinine and electrolytes
•	eGFR
•	fasting glucose
	Patient Self Management

Smoking Cease smoking 

Weight BMI < 25 kg/m2
WC males < 94 cm27 (< 90 cm in Asian populations) 
WC females < 80 cm27
Physical activity > 30 min. physical activity/day

Nutrition Dietary salt intake 40–100 mmol/day29

Alcohol Moderate alcohol consumption only (1–2 standard drinks/day)	
Goals of Stage 3 CKD management

– reduce progression of kidney disease
– reduce cardiovascular risk
– early detection and management
of complications
– avoidance of renally-excreted and
nephrotoxic medications
– adjustment of medication doses to levels
appropriate for kidney function
– appropriate referral when indicated	Monitoring in Stage 3 CKD

•	One to three monthly clinical review
•	clinical assessment
•	blood pressure(< 130/80 mmHg < 125/75 mmHg if proteinuria > 1g/24hrs)
•	weight
•	urine dipstick (> 50% reduction of baseline value)
•	laboratory assessment
•	biochemical profile including urea,
•	creatinine and electrolytes
•	eGFR
•	fasting glucose
•	fasting lipids
•	full blood count
•	iron stores
•	calcium and phosphate
– parathyroid hormone (quarterly)
	Patient Self Management

Smoking Cease smoking 

Weight BMI < 25 kg/m2
WC males < 94 cm27 (< 90 cm in Asian populations) 
WC females < 80 cm27
Physical activity > 30 min. physical activity/day

Nutrition Dietary salt intake 40–100 mmol/day29

Alcohol Moderate alcohol consumption only (1–2 standard drinks/day)
	
Goals of Stage 4 CKD management

– referral to a nephrologist for physical and
psychosocial preparation for renal replacement
therapy (dialysis, pre-emptive transplantation,
transplantation) or conservative management
– reduce progression of kidney disease
– reduce cardiovascular risk
– early detection and management
of complications
– avoidance of renally-excreted and
nephrotoxic medications
– adjustment of medication doses to levels
appropriate for kidney function

	Monitoring in Stage 4 CKD

– monthly clinical review
– clinical assessment
– blood pressure (< 130/80 mmHg < 125/75 mmHg if proteinuria > 1g/24hrs)
– weight
– oedema
– urine dipstick (> 50% reduction of baseline value)
– laboratory assessment
– biochemical profile including urea,
creatinine and electrolytes
– eGFR
– fasting glucose: (Pre-prandial BSL 4.4–6.7 mmol/L)
•	fasting lipids 
•	(Chol Total < 4.0 mmol/L
•	LDL < 2.5 mmol/L)
– full blood count
– iron stores
– calcium and phosphate
– parathyroid hormone (quarterly)	Patient Self Management

Smoking Cease smoking 

Weight BMI < 25 kg/m2
WC males < 94 cm27 (< 90 cm in Asian populations) 
WC females < 80 cm27
Physical activity > 30 min. physical activity/day

Nutrition Dietary salt intake 40–100 mmol/day29

Alcohol Moderate alcohol consumption only (1–2 standard drinks/day)
	
Goals of Stage 5 CKD management

– referral to a nephrologist for physical and
psychosocial preparation for renal replacement
therapy (dialysis, pre-emptive transplantation,
transplantation) or conservative management
– reduction in cardiovascular and kidney risk
– early detection and management
of complications
– avoidance of renally-excreted and
nephrotoxic medications
– adjustment of medication doses to	Monitoring in Stage 5 CKD

– monthly clinical review (shared with renal unit)
– clinical assessment
– blood pressure(< 130/80 mmHg < 125/75 mmHg if proteinuria > 1g/24hrs)
– weight
– oedema
– urine dipstick (> 50% reduction of baseline value)
– laboratory assessment
– biochemical profile including urea,
creatinine and electrolytes
– eGFR
– fasting glucose
– fasting lipids
– full blood count
– iron stores
– calcium and phosphate
– parathyroid hormone (quarterly)	Patient Self Management

Smoking Cease smoking 

Weight BMI < 25 kg/m2
WC males < 94 cm27 (< 90 cm in Asian populations) 
WC females < 80 cm27
Physical activity > 30 min. physical activity/day

Nutrition Dietary salt intake 40–100 mmol/day29

Alcohol Moderate alcohol consumption only (1–2 standard drinks/day)

Notes:        
     	

Capacity to self manage	
I have explored readiness for change and barriers for self management
I have checked that the patient has enough  knowledge, confidence and family support to manage the condition	
Contacts and further Information	

Kidney Health Info Line: Freecall 1800 682 531 or web: www.kidney.org.au

Further referrals	
Dietitian       
Nutritionist      
Exercise physiology      
Nephrologist:      	

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