Patient needs/ Goals- changes to be achieved Required treatments & Arrangements for Review, changes relevant conditions services including patient treatments/ services made on Date: actions (What, who) 1. Kidney Health Check eGFR GP to monitor (12 monthly review) Current: mL/min/1.73m2 Urine ACR Albuminuria present if urine ACR >3.5 GP to monitor (12 monthly review) mg/mmol in females and >2.5 Current: mg/mmol mg/mmol in males) ≤ 140/90 mmHg Blood pressure Lifestyle modification GP to monitor (12 or ≤ 130/80 mmHg in people with monthly review) Current: mmHg Pharmacological therapy albuminuria or diabetes 2. General Patient’s understanding Patient to have clear understanding of Patient education (list GP/ Nurse of chronic kidney chronic kidney disease & patient’s role resources, assistance given) disease in management the condition Chronic disease wellness program-Central intake unit ph: 1300 668 936 Patient’s understanding Patient to have clear understanding of Patient education (list GP/ Nurse of multi-chronic their other chronic condition(s)- resources, assistance given) conditions List here: Referral to specialist GP renal physician if GCUH outpatients ph no: required 1300 744 267 3. Laboratory assessments Biochemical profile GP/ Nurse (12 including urea, monthly review) creatinine and electrolytes Blood glucose (for Generally: ≤53 mmol/mol (range Lifestyle modification GP/ Nurse (12 people with diabetes) ≤7% (range 6.5-7.5). monthly review) Oral hypoglycaemics Current: mmol/mol Needs individualisation according to Gliptins patient circumstances (e.g., disease Incretin mimetics duration, life expectancy, important Insulin comorbidities, and established vascular complications). Refer to CKD Management in Lipids In adults with newly identified CKD, General Practice (3rd edition) evaluation with a fasting lipid profile Fasting lipid profile for advice regarding statin is recommended. therapy Follow up measurement of lipid levels is not required for the majority of patients
Patient needs/ relevant conditions Goals- changes to be achieved Required treatments & services including patient actions Arrangements for treatments/ services (What, who) Review, changes made on Date: 1. Kidney Health Check eGFR Current: mL/min/1.73m2 GP to monitor (12 monthly review) Urine ACR Current: mg/mmol Albuminuria present if urine ACR >3.5 mg/mmol in females and >2.5 mg/mmol in males) GP to monitor (12 monthly review) Blood pressure Current: mmHg ≤ 140/90 mmHg or ≤ 130/80 mmHg in people with albuminuria or diabetes Lifestyle modification Pharmacological therapy GP to monitor (12 monthly review) 2. General Patient’s understanding of chronic kidney disease Patient to have clear understanding of chronic kidney disease & patient’s role in management the condition Patient education (list resources, assistance given) Chronic disease wellness program-Central intake unit ph: 1300 668 936 GP/ Nurse Patient’s understanding of multi-chronic conditions Patient to have clear understanding of their other chronic condition(s)- List here: Patient education (list resources, assistance given) GP/ Nurse Referral to specialist renal physician if required GCUH outpatients ph no: 1300 744 267 GP 3. Laboratory assessments Biochemical profile including urea, creatinine and electrolytes GP/ Nurse (12 monthly review) Blood glucose (for people with diabetes) Current: mmol/mol Generally: ≤53 mmol/mol (range ≤7% (range 6.5-7.5). Needs individualisation according to patient circumstances (e.g., disease duration, life expectancy, important comorbidities, and established vascular complications). Lifestyle modification Oral hypoglycaemics Gliptins Incretin mimetics Insulin GP/ Nurse (12 monthly review) Lipids Fasting lipid profile In adults with newly identified CKD, evaluation with a fasting lipid profile is recommended. Follow up measurement of lipid levels is not required for the majority of patients Refer to CKD Management in General Practice (3rd edition) for advice regarding statin therapy
GP-CKD-ACTION-PLAN-YELLOW.docx