CKD Pathway - Medical Management

Prescribing Information

Diabetes	No Diabetes
Prescribe an ACEi or ARB unless contraindicated.	Prescribe an ACEi or ARB if ACR > 30 mg/mmol and no contraindications.

Dosage

Titrate to maximum tolerated dose.

Contra-
indications

Pregnancy
Women with childbearing potential should only use an ACEi or ARB if there is reliable contraception.

General
Information

Check potassium and eGFR within 2 weeks of starting or dose changes.
Combined therapy of ACEi and ARB not recommended.
ACEi or ARBs can cause a reversible reduction in eGFR when treatment is initiated (approximately 25%):
- » If the reduction in eGFR exceeds 25% below the baseline value, stop ACEi or ARB.
- » If the reduction in eGFR is 5 to 25%, re-check in 2-3 weeks to exclude further deterioration.
Increases in serum potassium of up to 0.5mmol/L can be expected with ACEi or ARB use.
ACEi or ARBs can safely be prescribed at all stages of CKD and should not be deliberately avoided with reduced eGFR.
Assess for baseline cough, if bothersome cough with ACEi consider switching to ARB.
Check the potassium and eGFR in times of acute illness, particularly influenza and diarrheal illness.

Prescribing Information

Diabetes	No Diabetes
Prescribe statin unless contraindicated.	Age > 50: Prescribe statin unless contraindicated. Age 18 – 49 : Prescribe statin if no contraindications and if any one of the following: Known coronary disease (myocardial infarction or coronary revascularization). Prior ischemic stroke. Estimated 10-year incidence of coronary death or non-fatal MI >10%. (Calculate your Patient's Framingham Risk Score)

Dosage

Recommended doses (mg/d) of statins in adults with CKD

Contra-
indications

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

General
Information

No follow-up monitoring of lipid levels required unless the result will change course of therapy.
Measure ALT prior to starting a statin. Follow-up monitoring not required as abnormalities are low in patients with normal baseline ALT.
CK not required at baseline or during follow-up unless patient develops symptoms suggestive of myopathy.

Prescribing Information

Diabetes	No Diabetes
Low dose ASA (81mg) may be used for secondary prevention in patients with established vascular disease: Acute coronary syndrome Prior MI or coronary revascularization Prior stroke or TIA PVD (high risk patients with low bleeding risk).