Pediatric patients (protein intake): avoid offering protein intake restrictions for preventive effects in pediatric patients with CKD. D Pediatric patients, immunizations: As per JSN 2019 guidelines, provide routine immunizations in pediatric patients with CKD as they are susceptible to infections likely to become severe. B As per KDIGO 2013 guidelines, follow to of cial international and regional recommedations for pediatric immunization schedules for pediatric patients with CKD. Pediatric patients, management of hypertension: As per KDIGO 2021 guidelines, consider lowering 24-hour mean arterial pressure by ambulatory BP monitoring to 50th percentile for age, sex, and height in pediatric patients with CKD. C Show 3 more As per JSN 2019 guidelines, consider initiating antihypertensive therapy along with lifestyle instruction and medication including RAAS inhibitors and calcium antagonists, on an individual basis and according to age, in pediatric patients with CKD and hypertension. C As per KDIGO 2013 guidelines, initiate BP-lowering agents in children with non-dialysis- dependent CKD whose BP is consistently above the 90th percentile for age, sex, and height. B Show 2 more Pediatric patients, management of mineral and bone disorder: As per JSN 2019 guidelines, treat CKD-mineral and bone disorder in pediatric patients with CKD to improve bone lesions and cardiovascular function. Consider maintaining the corrected serum levels of calcium and phosphorus within normal ranges in accordance with the patient's age. B As per JSN 2019 guidelines, treat CKD-mineral and bone disorder in pediatric patients with CKD to improve bone lesions and cardiovascular function. Consider maintaining the corrected serum levels of calcium and phosphorus within normal ranges in accordance with the patient's age. B As per KDIGO 2017 guidelines, consider maintaining serum calcium in the age-appropriate normal range in pediatric patients with CKD stages G3a-G5D. C Consider administering calcitriol and vitamin D analogs to maintain serum calcium levels in the age-appropriate normal range in pediatric patients. Show 3 more As per JSDT 2013 guidelines, consider starting monitoring of serum phosphorus, calcium, albumin, PTH, ALP, and bicarbonate ion concentration in stage 2 of CKD. C Show 4 more Pediatric patients (management of growth stunting): consider administering recombinant human GH in pediatric patients with CKD with growth stunting. B Pediatric patients (kidney transplantation): consider performing preemptive kidney transplantation in pediatric patients with CKD. C https://web.pathway.md/diseases/recIwpUFjFfYxzh1Y 15/32 6/29/23, 3:54 AM Chronic kidney disease Pathway Pediatric patients (patients with HIV infection): screen renal function with eGFR (using an estimating equation developed for children) when antiretroviral is initiated or changed, and at least twice yearly in pediatric and adolescent patients with human immunodeficiency virus without evidence of existing kidney disease. Monitor for kidney damage with urinalysis or a quantitative measure of proteinuria when antiretroviral therapy is initiated or changed, and at least annually in pediatric and adolescent patients with stable kidney function. Consider obtaining more frequent monitoring in patients with additional kidney disease risk factors. B Show 4 more Elderly patients (evaluation): use estimating equations correcting for differences in creatinine generation rather than plain serum creatinine measurements to assess kidney function in older patients. A Show 3 more Elderly patients (prognostic scores): use a simple score on a regular basis to assess functional status in older patients with CKD stage 3b-5d with the intention to identify patients who would benefit from a more in-depth geriatric assessment and rehabilitation. B Show 5 more Elderly patients (physical activity): advise exercising to improve the functional status in older patients with CKD stage 3b. B Offer exercise training in a structured and individualized manner to avoid adverse events. B Elderly patients (nutritional assessment): use the Subjective Global Assessment as the gold standard to assess the nutritional status in older patients with CKD stage 3b (eGFR < 45mL/min/1.73 m ). B Show 2 more Elderly patients (glycemic targets): implement strict glycemic therapy in 75 years old patients with CKD and diabetes mellitus as they are at risk of severe hypoglycemia. Consider deciding the target for glycemic control individually depending on the patient's health condition (age, cognitive function, physical function, comorbidity, risk of hypoglycemia, and time to live). B Elderly patients, renal adjustment of medications: As per JSN 2019 guidelines, pay attention to the control of doses of RAAS inhibitors, diuretics, vitamin D, and other frequently used drugs since metabolic and excretion rates decline in elderly patients with CKD. Consider checking the medication notebook to avoid polypharmacy. B As per ACP 2016 guidelines: Take into account kidney function when prescribing drugs whose active forms or metabolites are excreted renally. A Consider obtaining regular measurements of serum drug concentrations for drugs with a narrow toxic/therapeutic range. Consider using different target levels of total drug concentration because of the differences in protein binding in relation to uremia. C Elderly patients (BP targets): set a target BP < 150/90 mmHg (but no less than 110 mmHg of systolic BP) in elderly patients with hypertension and CKD. Set a target BP < 140/90 mmHg in https://web.pathway.md/diseases/recIwpUFjFfYxzh1Y 16/32 6/29/23, 3:54 AM Chronic kidney disease Pathway elderly patients with hypertension and CKD if antihypertensive agents are tolerated without any adverse events. B Elderly patients (lipid-lowering therapy): consider initiating lipid-lowering therapy (statin alone or a statin and ezetimibe combination) in 65-71 years old patients with CKD. Initiate lipid-lowering therapy in 75 years old patients for decreasing all-cause mortality and for primary or secondary prevention of CVD. C Elderly patients (renal replacement therapy): Use validated tools to project likely outcomes and help decide the appropriateness of discussing options for RRT. Discuss the option for conservative management during the shared decision-making process on different management options for end-stage renal disease. B Elderly patients (management of anemia): consider maintaining Hgb levels within the target range of 11-13 g/dL using ESAs and/or iron supplementation in elderly patients (aged 75 years) with non-dialysis CKD and anemia. Consider lowering the lower limit of the target range to 9 g/dL with respect to the mortality risk. Remove clinical factors associated with resistance to ESAs to avoid the use of high-dose ESAs. C Elderly patients (management of hyperphosphatemia): advise limiting dietary phosphate intake and/or consider offering phosphate binders to maintain serum phosphate levels within the normal range in elderly patients (aged 75 years) with non-dialysis CKD. Obtain close monitoring for adverse effects to prevent malnutrition since the phosphate-lowering therapies may cause loss of appetite. B Elderly patiants (management of hyperparathyroidism): consider lowering PTH levels within the normal range by treating abnormalities in serum phosphate and calcium levels before administering active vitamin D agents in elderly patients with non-dialysis CKD with secondary hyperparathyroidism. Avoid hypercalcemia when using active vitamin D agents. C Pregnant patients: As per KDIGO 2020 guidelines, advise contraception in female patients receiving ACEI or ARB therapy and discontinue these agents in patients considering pregnancy or becoming pregnant. B As per JSN 2019 guidelines: Recognize that patients with CKD have higher risks of pregnancy complications, such as preeclampsia, premature birth, or fetal loss, even in the CKD stage G1. Recognize that the risk is higher in patients with a higher CKD stage. B Consider initiating methyldopa, labetalol, hydralazine, or slow-release nifedipine after the 20th week of gestation when antihypertensive therapy is required in pregnant patients with CKD. Do not use ACEIs and ARBs in pregnant patients. C Patients with diabetes mellitus, primary prevention: As per ADA 2023 guidelines: Optimize glucose control to reduce the risk of CKD. A https://web.pathway.md/diseases/recIwpUFjFfYxzh1Y 17/32 6/29/23, 3:54 AM Chronic kidney disease Pathway Optimize BP control and reduce BP variability to reduce the risk or slow the progression of CKD. A As per Diabetes Canada 2018 guidelines, aim to achieve optimal control of blood glucose and BP in order to prevent the onset of CKD in patients with diabetes. A Patients with diabetes mellitus, general principles of management: As per ADA 2023 guidelines: Optimize glucose control to slow the progression of CKD. A Optimize BP control and reduce BP variability to reduce the risk or slow the progression of CKD. A As per KDIGO 2020 guidelines, include lifestyle therapy, first-line treatment with metformin and an SGLT-2 inhibitor, and additional drug therapy as needed for glycemic management of patients with T2DM and CKD. B Show 2 more As per Diabetes Canada 2018 guidelines: Aim to achieve optimal control of blood glucose and BP in order to delay the progression of CKD in patients with diabetes. A Ensure a comprehensive, multifaceted approach to reduce cardiovascular risk in all patients with diabetes and CKD. A As per KDIGO 2013 guidelines, implement a multifactorial intervention strategy in patients with diabetes and CKD, including glycemic control, BP reduction, and cardiovascular risk. Initiate ACEIs or ARBs, statins, and antiplatelet therapy where clinically indicated. Updated evidence: CREDENCE In patients with T2DM and kidney disease, canagliflozin was superior to placebo with respect to the incidence of ESRD, doubling of creatinine, renal death, or CV death. Perkovic V et al. N Engl J Med. 2019 Jun 13. Patients with diabetes mellitus (team-based care): Implement (by policymakers and institutional decision-makers) team-based, integrated care focused on risk evaluation and patient empowerment to provide comprehensive care in patients with diabetes and CKD. B Deliver team-based integrated care (supported by decision-makers) by physicians and non- physician personnel (such as trained nurses and dietitians, pharmacists, healthcare assistants, community workers, and peer supporters) preferably with knowledge of CKD. B Patients with diabetes mellitus (self-management programs): Implement a structured self-management education program for the care of patients with diabetes and CKD. B https://web.pathway.md/diseases/recIwpUFjFfYxzh1Y 18/32 6/29/23, 3:54 AM Chronic kidney disease Pathway Consider implementing a structured self-management program in healthcare systems for patients with diabetes and CKD, taking into consideration local context, cultures, and availability of resources. C Patients with diabetes mellitus, indications for specialist referral: As per ADA 2023 guidelines: Refer patients for evaluation by a nephrologist if urinary albumin levels are continuously increasing and/or eGFR is continuously decreasing or is < 30 mL/min/1.73 m . A Refer patients promptly to a nephrologist for uncertainty about the etiology of kidney disease, difficult management issues, and rapidly progressing kidney disease. A As per Diabetes Canada 2018 guidelines, refer patients with diabetes to a specialist with expertise in CKD in the following situations: chronic, progressive loss of kidney function urine albumin-to-creatinine ratio persistently > 60 mg/mmol eGFR < 30 mL/min inability to remain on renal-protective therapies due to adverse effects, such as hyperkalemia or a > 30% increase in serum creatinine within 3 months of starting an ACEI or ARB inability to achieve target BP. B Patients with diabetes mellitus, treatment goals: As per ADA 2023 guidelines, reduce urinary albumin by 30% to slow CKD progression in patients with CKD with 300 mg/g of urinary albumin. B As per KDIGO 2020 guidelines, set an individualized HbA1c target in the range of < 6.5-8.0% in patients with diabetes and CKD not treated with dialysis. B Show 2 more As per ERBP 2015 guidelines, do not apply tighter glycemic control if it results in severe hypoglycemic episodes. D Show 2 more As per KDIGO 2013 guidelines, set a target HbA1c of ~ 7.0% (53 mmol/mol) to prevent or delay the progression of microvascular complications, including diabetic kidney disease. B Show 2 more Patients with diabetes mellitus, glycemic monitoring: As per KDIGO 2020 guidelines, assess HbA1c level to monitor glycemic control in patients with diabetes and CKD. B Show 5 more As per ERBP 2015 guidelines, obtain HbA1c measurements to assess long-term glycemic control in patients with CKD stage 3b (eGFR < 45 mL/min/1.73 m ). B Patients with diabetes mellitus (monitoring of renal function): Assess urinary albumin (such as spot urinary albumin-to-creatinine ratio) and eGFR at least annually in all patients with T2DM regardless of treatment. B https://web.pathway.md/diseases/recIwpUFjFfYxzh1Y 19/32 6/29/23, 3:54 AM Chronic kidney disease Pathway Monitor urinary albumin (such as spot urinary albumin-to-creatinine ratio) and eGFR 1-4 times per year depending on the stage of the disease in patients with established diabetic kidney disease. B Patients with diabetes mellitus, weight loss: As per KDIGO 2020 guidelines, consider advising/encouraging patients with obesity, diabetes, and CKD to lose weight, particularly patients with an eGFR 30 mL/min/1.73 m . C As per ERBP 2015 guidelines, ensure supervision by a dietitian when promoting weight loss in overweight patients with diabetes to ensure that only fat mass is lost and to avoid malnutrition. B Patients with diabetes mellitus, physical activity: As per KDIGO 2020 guidelines, advise practicing moderate-intensity physical activity for a cumulative duration of at least 150 minutes/week, or to a level compatible with their cardiovascular and physical tolerance, in patients with diabetes and CKD, B taking into account age, ethnic background, presence of other comorbidities, and access to resources. B Show 2 more As per ERBP 2015 guidelines, consider advising patients with diabetes and CKD stage 3b (eGFR < 45 mL/min) to practice additional physical exercise at least 3 times 1/2 to 1 hour/week to reduce fat mass and improve quality of life. C Patients with diabetes mellitus (dietary modifications): advise an individualized diet high in vegetables, fruits, whole grains, fiber, legumes, plant-based proteins, unsaturated fats, and nuts, and lower in processed meats, refined carbohydrates, and sweetened beverages in patients with diabetes and CKD. B Show 3 more Patients with diabetes mellitus, protein intake: As per ADA 2023 guidelines, aim to a target level of 0.8 g/kg body weight/day of dietary protein intake in patients with nondialysis-dependent stage 3 CKD. A Consider allowing higher levels of dietary protein intake in patients on dialysis since protein energy wasting is a major problem in some patients on dialysis. B As per KDIGO 2020 guidelines: Consider maintaining a protein intake of 0.8 g protein/kg/day in patients with diabetes and CKD not treated with dialysis. C Ensure consumption of 1.0-1.2 g protein/kg/day in patients on hemodialysis, particularly peritoneal dialysis. B Patients with diabetes mellitus (sodium intake): consider ensuring sodium intake of < 2 g of sodium per day (or < 90 mmol of sodium per day, or < 5 g of sodium chloride per day) in patients with diabetes and CKD. C Patients with diabetes mellitus (smoking cessation): Advise patients with diabetes and CKD to quit using tobacco products. B Counsel patients with diabetes and CKD to reduce secondhand smoke exposure. B https://web.pathway.md/diseases/recIwpUFjFfYxzh1Y 20/32 6/29/23, 3:54 AM Chronic kidney disease Pathway Patients with diabetes mellitus, metformin: As per KDIGO 2020 guidelines, initiate metformin in patients with T2DM and CKD with an eGFR 30 mL/min/1.73 m , B including kidney transplant recipients. B Show 2 more As per ERBP 2015 guidelines, initiate metformin in a dose adapted to renal function as a first- line agent when lifestyle measures alone are insufficient to get HbA1c in the desired range. B Show 2 more Patients with diabetes mellitus, RAAS blockers: As per ADA 2023 guidelines, do not use ACEIs or ARBs for the primary prevention of CKD in patients with diabetes with normal BP, normal urinary albumin-to-creatinine ratio (< 30 mg/g creatinine), and normal eGFR. D Show 5 more As per KDIGO 2020 guidelines, initiate an ACEI or an ARB in patients with diabetes, hypertension, and albuminuria, and titrate to the highest approved and tolerated dose. B Show 8 more As per Diabetes Canada 2018 guidelines, initiate ACEIs or direct renin inhibitors to delay the progression of CKD in adult patients with diabetes and CKD with either hypertension or albuminuria. A Show 2 more Landmark trials: VA-NEPHRON D In patients with T2DM, a urinary albumin-to-creatinine ratio of at least 300, and an eGFR of 30.0 to 89.9 mL/min/1.73 m of body-surface area, combined angiotensin inhibition was not superior to monotherapy with respect to decline in eGFR (by 30 mL/min if eGFR 60-90 at baseline, or by 50% eGFR 30-60 at baseline), ESRD, or death. Fried LF et al. N Engl J Med. 2013 Nov 14. As per ERBP 2015 guidelines, initiate ACEIs at a maximally tolerated dose in adult patients with CKD stage 3b (eGFR < 45 mL/min/1.73 m or on dialysis) and diabetes having a cardiovascular indication (HF, ischemic heart disease). B Show 2 more Patients with diabetes mellitus (beta-blockers): Consider initiating selective -blockers for primary prevention in patients with diabetes and CKD stage 3b, and then continuing if tolerated. C Consider preferring lipophilic over hydrophilic -blockers in patients with diabetes and CKD stage 3b (eGFR < 45 mL/min/1.73 m ). C Patients with diabetes mellitus, SGLT2 inhibitors: As per ADA 2023 guidelines, initiate SGLT-2 inhibitors in patients with an eGFR 25 mL/min/1.73 m and urinary albumin 300 mg/g creatinine to reduce CKD progression and https://web.pathway.md/diseases/recIwpUFjFfYxzh1Y 21/32 6/29/23, 3:54 AM Chronic kidney disease Pathway cardiovascular events in patients with T2DM and diabetic kidney disease. A Show 2 more As per KDIGO 2020 guidelines, initiate an SGLT-2 inhibitor in patients with T2DM and CKD with an eGFR 30 mL/min/1.73 m . B Show 8 more As per Diabetes Canada 2018 guidelines, consider initiating sodium-glucose cotransporter 2 inhibitors with proven renal benefit, such as empagliflozin C or canagliflozin, C to reduce the risk of progression of nephropathy in adult patients with T2DM with clinical CVD and an eGFR > 30 mL/min/1.73 m , if glycemic targets are not achieved with existing antihyperglycemic medications. C Patients with diabetes mellitus (GLP-1 receptor agonists): initiate a long-acting GLP-1 receptor agonist in patients with T2DM and CKD failed to achieve individualized glycemic targets despite the use of metformin and an SGLT-2 inhibitor, or being unable to use those medications. B Show 4 more Patients with diabetes mellitus (statin therapy): initiate statin therapy in patients with diabetes and CKD stage 3b-4. B Show 2 more Patients with diabetes mellitus (antiplatelet therapy): do not add glycoprotein IIb/IIIa inhibitors to standard care to reduce mortality, myocardial infarction, or need for coronary revascularization in patients with diabetes and CKD stage 3b (eGFR < 45 mL/min/1.73 m ) and acute coronary syndromes or high-risk coronary artery intervention. D Show 3 more Patients with diabetes mellitus (renal replacement therapy): give priority to the patient's general status and preference in selecting RRT as there is an absence of evidence of the superiority of one modality over another in patients with diabetes and CKD stage 5. B Show 5 more Patients with diabetes mellitus (kidney transplantation): provide education on the different options of transplantation and their expected outcomes in patients with diabetes and CKD stage 4-5 deemed suitable for transplantation. B Show 5 more Patients with cardiovascular disease: As per ERBP 2015 guidelines, do not omit coronary angiography with the sole intention of avoiding potential contrast-related deterioration of kidney function in patients with diabetes and chronic stage 3b (eGFR < 45mL/min/1.73 m ) if coronary angiography is indicated. D Show 3 more As per KDIGO 2013 guidelines, view all patients with CKD as being at increased risk for CVD. B Show 6 more Patients with osteoporosis (bisphosphonates): avoid prescribing bisphosphonates without a strong clinical rationale in patients with GFR < 30 mL/min/1.73 m . D https://web.pathway.md/diseases/recIwpUFjFfYxzh1Y 22/32 6/29/23, 3:54 AM Chronic kidney disease Pathway Patients with osteoporosis (monitoring): avoid obtaining bone mineral density testing routinely in patients with CKD and an eGFR < 45 mL/min/1.73 m , as information may be misleading or unhelpful. D Patients with cancer: avoid denying cancer treatment on the sole basis of CKD. Adjust doses of cytotoxic drugs according to GFR. Patients with HCV infection (liver testing): Assess patients with CKD and HCV infection for liver fibrosis, B initially with noninvasive methods. B Assess patients with CKD and suspected advanced fibrosis (F3-4) for portal hypertension. B Patients with HCV infection (screening for other infections): screen for HAV, HBV, and human immunodeficiency virus in all patients with HCV infection (whether nucleic acid testing-positive or not) and CKD. Offer vaccination against HAV and HBV if appropriate. B Show 2 more Patients with HCV infection, antiviral regimens: As per IDSA/AASLD 2020 guidelines, do not adjust doses of direct-acting antiviral therapy when using recommended regimens in patients with stage 1, 2, or 3 D and 4 or 5 CKD, except consider adjusting ribavirin dose in patients with stage 3, 4, or 5 CKD. D As per KDIGO 2018 guidelines, assess all patients with CKD and HCV infection for antiviral therapy. B Show 5 more Patients with HCV infection (management of glomerular disease): initiate treatment for HCV infection in patients with HCV-associated glomerular disease. B Show 4 more Patients with HCV infection, kidney transplantation: As per KDIGO 2018 guidelines, offer kidney transplantation as the best therapeutic option in patients with CKD stage G5 irrespective of the presence of HCV infection. B Show 7 more As per KDIGO 2008 guidelines, avoid viewing HCV infection as a contraindication for kidney transplantation. D Show 2 more Patients with HCV infection (follow-up): obtain regular monitoring to assess kidney disease progression in all patients with CKD with a history of HCV infection, whether nucleic acid testing- positive or not. B Patients with HIV infection (monitoring of renal function): Obtain monitoring with creatinine-based eGFR when antiretroviral therapy is initiated or changed, and at least twice yearly in stable patients with human immunodeficiency virus, using the same estimation method to track trends over time. Consider obtaining more frequent monitoring in patients with additional kidney disease risk factors. B https://web.pathway.md/diseases/recIwpUFjFfYxzh1Y 23/32 6/29/23, 3:54 AM Chronic kidney disease Pathway Consider monitoring kidney damage with urinalysis or a quantitative measure of albuminuria/proteinuria at baseline, when antiretroviral therapy is initiated or changed, and at least annually in stable patients with human immunodeficiency virus. Consider obtaining more frequent monitoring in patients with additional kidney disease risk factors. C Patients with HIV infection (evaluation for kidney disease): Obtain the following for the evaluation of new-onset or newly discovered kidney disease in patients with human immunodeficiency virus serum chemistry panel complete urinalysis quantitation of albuminuria (albumin-to-creatinine ratio from spot sample or total albumin from 24-hour collection) assessment of temporal trends in eGFR BP blood glucose (in patients with diabetes) markers of proximal tubular dysfunction (particularly if treated with tenofovir) renal ultrasound review of prescription and OTC medications likely to cause kidney injury or require dose modification for decreased kidney function. B Refer patients with human immunodeficiency virus with kidney disease to a nephrologist for diagnostic evaluation in case of any of the following: clinically significant decline in GFR (> 25% from baseline and to a level < 60 mL/min/1.73 m ) failed to resolve after potential nephrotoxic drugs are removed albuminuria > 300 mg/day hematuria with either albuminuria/proteinuria or increased BP for advanced CKD management (glomerular filtration ratio < 30 mL/min/1.73 m ). B Patients with HIV infection (antiretroviral therapy): initiate antiretroviral therapy and encourage persistence with therapy in patients with human immunodeficiency virus infection with CKD or end-stage renal disease, as antiretroviral therapy reduces mortality but is underused in this patient population. B Show 4 more Patients with HIV infection (RAAS blockers): initiate ACEIs or ARBs, when clinically feasible, in patients with confirmed or suspected human immunodeficiency virus-associated nephropathy or clinically significant albuminuria (> 30 mg/day in diabetic patients, > 300 mg/day in non-diabetic patients). A Patients with HIV infection (statins): initiate statins to prevent CVD as appropriate in individuals in the highest cardiovascular risk group (> 7.5% 10-year risk of CVD) in patients with human immunodeficiency virus infection with pre-end-stage renal disease CKD. A Patients with HIV infection (aspirin): consider initiating aspirin (75-100 mg/day) to prevent CVD in patients with human immunodeficiency virus infection with CKD, balancing the benefit of aspirin https://web.pathway.md/diseases/recIwpUFjFfYxzh1Y 24/32 6/29/23, 3:54 AM Chronic kidney disease Pathway against the patient's risk of bleeding. B Patients with HIV infection (BP targets): Set a BP < 140/90 mmHg as the target in patients with human immunodeficiency virus infection with CKD with normal-to-mild albuminuria (< 30 mg/day or equivalent). B Consider setting a BP < 130/80 mmHg as the target in patients with human immunodeficiency virus infection with CKD with moderate-to-severe albuminuria (> 30-300 mg/day or equivalent). C Patients with HIV infection (corticosteroids): consider administering corticosteroids as an adjunct to antiretroviral therapy and ACEIs or ARBs in patients with biopsy-confirmed human immunodeficiency virus-associated nephropathy. C Patients with HIV infection (renal replacement therapy): Establish permanent dialysis access when possible, ideally an arteriovenous fistula or peritoneal catheter, before the anticipated initiation of RRT to avoid the use of higher-risk central venous catheters for hemodialysis. B Avoid using peripherally inserted central catheters and subclavian central venous catheters when possible in patients with human immunodeficiency virus anticipated to need dialysis in the future, because these devices can damage veins and limit options for permanent hemodialysis access. D Patients with HIV infection (kidney transplantation): Assess patients with human immunodeficiency virus and end-stage renal disease or imminent end-stage renal disease for the possibility of kidney transplantation, taking into account the history of opportunistic conditions, comorbidities, current immune status, and virologic control of human immunodeficiency virus with antiretroviral therapy. B Adjust the doses and monitor immunosuppressant drugs to account for pharmacologic interactions with antiretroviral drugs in patients with human immunodeficiency virus infection after kidney transplantation. Attempt choosing antiretroviral agents, when feasible, carrying minimal risks of interactions with immunosuppressant drugs. B Patients with HIV infection (pediatric patients): screen renal function with eGFR (using an estimating equation developed for children) when antiretroviral is initiated or changed, and at least twice yearly in pediatric and adolescent patients with human immunodeficiency virus without evidence of existing kidney disease. Monitor for kidney damage with urinalysis or a quantitative measure of proteinuria when antiretroviral therapy is initiated or changed, and at least annually in pediatric and adolescent patients with stable kidney function. Consider obtaining more frequent monitoring in patients with additional kidney disease risk factors. B Show 4 more 9. Patient education Over-the-counter medicines and supplements: https://web.pathway.md/diseases/recIwpUFjFfYxzh1Y 25/32 6/29/23, 3:54 AM Chronic kidney disease Pathway Advise adults with CKD to seek medical or pharmacist advice before using OTC medicines or nutritional protein supplements. B Avoid herbal remedies in patients with CKD. D 10. Preventative measures Immunizations: As per JSN 2019 guidelines, consider offering pneumococcal and influenza vaccination in patients with CKD. C As per KDIGO 2013 guidelines, provide influenza immunization on an annual basis in adult patients with CKD , unless contraindicated. B Show 3 more Use of contrast media, iodine-containing: As per JSN 2019 guidelines: Recognize that all patients with GFR < 60 mL/min/1.73 m (GFR categories G3a-5) are at risk for contrast media-induced nephropathy, especially in patients with GFR < 45 mL/min/1.73 m (GFR categories G3b-5) or if a large amount of iodinated radiocontrast media was used. B Obtain informed consent, ensure sufficient hydration with saline before, during, and after the procedure, and use the lowest possible iodinated radiocontrast media dose if the radiography with intravascular administration of iodinated radiocontrast media is required in patients with GFR < 60 mL/min/1.73 m (GFR categories G3a-5). B As per KDIGO 2013 guidelines, implement the following strategies to prevent contrast-induced nephropathy in patients with GFR < 60 mL/min/1.73 m undergoing elective investigation involving the intravascular administration of iodinated radiocontrast media: avoidance of high osmolar agents B use of lowest possible radiocontrast dose withdrawal of potentially nephrotoxic agents before and after the procedure B adequate hydration with saline before, during, and after the procedure B measurement of GFR 48-96 hours after the procedure B Use of contrast media (gadolinium-containing): Balance the risk of contrast-induced nephropathy against the diagnostic and therapeutic value of investigations requiring administration of intravenous contrast. Avoid gadolinium-containing contrast media in people with GFR < 15 mL/min/1.73 m (GFR category G5), unless there is no alternative appropriate test. D 11. Follow-up and surveillance Indications for sepcialist referral: Refer patients with CKD for specialist evaluation in the following circumstances: https://web.pathway.md/diseases/recIwpUFjFfYxzh1Y 26/32 6/29/23, 3:54 AM Chronic kidney disease Pathway AKI or abrupt sustained fall in GFR GFR < 30 mL/min/1.73 m significant albuminuria with albumin to creatinine ratio 300 mg/g ( 30 mg/mmol) or albumin excretion rate 300 mg/day, approximately equivalent to protein-to-creatinine ratio 500 mg/g ( 50 mg/mmol) or protein excretion rate 500 mg/day) progression of CKD urinary red cell casts, or RBC > 20/hpf sustained and not readily explained CKD and hypertension refractory to treatment with 4 antihypertensive agents persistent abnormalities of serum potassium recurrent or extensive nephrolithiasis hereditary kidney disease. B Monitoring for disease progression: assess GFR and albuminuria at least annually in people with CKD. Repeat testing more often in patients at higher risk of progression and/or where measurement will impact therapeutic decisions. Show 5 more Clinical findings Symptoms Past medical history Bone pain AKI Chest pain Acute pyelonephritis Erectile dysfunction Alport syndrome Fatigue Benign prostatic hyperplasia Headache CVD Hematuria Coronary artery disease Hiccups Diabetes mellitus Itching Diabetic nephropathy Loss of appetite Fabry disease Muscle cramps Glomerulonephritis Nausea HCV infection Seizure Hypertension Shortness of breath Kidney stones Sleeping disorder Multiple myeloma Vomiting Obesity Weight loss Polycystic kidney disease Pulmonary hypertension Medication history Renal artery stenosis SLE NSAIDs Sarcoidosis Anthropomorphic exam Sickle cell disease https://web.pathway.md/diseases/recIwpUFjFfYxzh1Y 27/32 6/29/23, 3:54 AM Chronic kidney disease Pathway Growth restriction Social history Neurological exam Tobacco use Cognitive impairment Vascular exam Coma Peripheral edema Peripheral neuropathy Cardiac exam Integument exam Pericarditis Lindsay's nails Pallor Lab findings Hematological findings Lactic acidosis PTH Anemia serum anion gap serum creatinine serum cystatin C serum phosphate serum urea urine protein GFR serum calcium H Studies 2023 DAPA-CKD (post-hoc analysis) In patients with CKD with and without anemia, dapagliflozin was superior to placebo with respect to improvement in hematocrit during follow-up. Akihiko Koshino et al. NEJM Evid. 2023. 2023 EMPA-KIDNEY In patients with CKD with an eGFR 20 and < 45 mL/min/1.73 m , or 45 and < 90 mL/min/1.73 m with a urinary albumin-to-creatinine ratio 200, empagliflozin was superior to placebo with respect to progression of kidney disease or death from cardiovascular causes. EMPA-KIDNEY Collaborative Group et al. N Engl J Med. 2023 Jan 12. Show 18 more References 1. KDIGO Executive Committee. KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. KDIGO. 2013 Jan;3 1 . Open https://web.pathway.md/diseases/recIwpUFjFfYxzh1Y 28/32 6/29/23, 3:54 AM Chronic kidney disease Pathway 2. KDIGO Executive Committee. KDIGO Clinical Practice Guideline for Anemia in Chronic Kidney Disease. KDIGO. 2012 Aug. Open 3. ERBP. Clinical Practice Guideline on management of patients with diabetes and chronic kidney disease stage 3b or higher (eGFR 45 mL/min). Nephrol Dial Transplant. 2015 May;30 Suppl 2:ii1 142. Open 4. Japanese Society of Nephrology. Essential points from Evidence-based Clinical Practice Guidelines for Chronic Kidney Disease 2018. Clin Exp Nephrol. 2019 Jan;23 1 1 15. Open 5. Kidney Disease: Improving Global Outcomes KDIGO Blood Pressure Work Group. KDIGO 2021 Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease. Kidney Int. 2021 Mar;99 3S S1 S87. Open 6. Kidney Disease: Improving Global Outcomes KDIGO Diabetes Work Group. KDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease. Kidney Int. 2022 Nov;102 5S S1 S127. Open 7. Kidney Disease: Improving Global Outcomes KDIGO Diabetes Work Group. KDIGO 2020 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease. Kidney Int. 2020 Oct;98 4S S1 S115. Open 8. Gregory M Lucas, Michael J Ross, Peter G Stock et al. 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