1. Clinical Toolkit Presentation Insert Name Insert Date
Target Audience – Intended for primary care providers.
Purpose: Educate on how to identify, detect, and manage CKD in primary care using the KidneyWise Clinical Toolkit. Length of Presentation: 30 minute talk.

2. Objective
To recognize and predict which patients in a typical family practice are at highest risk for chronic kidney disease (CKD) – Identification
To clarify which investigations to order when screening for CKD and how to interpret the results – Detection
To describe the role of the primary care provider (PCP) in managing patients with CKD and the criteria for appropriate referral to nephrology – Management
To introduce the ORN KidneyWise Clinical Toolkit that summarizes the above and promotes a model of shared care
This slide lists the objectives for today's talk. The first objective is to recognize and predict which patients in a typical family practice are at highest risk for chronic kidney disease or CKD. This is known as identification.
The next objective is to clarify which investigations to order when screening for CKD and how to interpret the results. This is known as detection.
The third objective is to describe the role of the primary care provider in managing patients with CKD and the criteria for appropriate referral to nephrology. This is known as management.
And finally, the fourth objective of this talk is to introduce the Ontario Renal Network KidneyWise Clinical Toolkit that summarizes the above and promotes a model of shared care.

3. About the Ontario Renal Network
Responsible for overseeing and funding the delivery of chronic kidney disease (CKD) services across Ontario
Ontario Renal Plan II is a roadmap that outlines how the ORN will try to improve the lives of those living with CKD
Delaying the progression of CKD to end stage kidney disease, while improving access to care and services for those living with the disease in Ontario is a main priority
The next slide talks a little bit about the Ontario Renal Network. The Ontario Renal Network is responsible for overseeing and funding the delivery of CKD services across Ontario. 
To read more about the Ontario Renal Network, you can look up the Ontario Renal Plan II, which is a roadmap that outlines how the Ontario Renal Network will try to improve the lives of those living with chronic kidney disease. 
One of the main priorities of the Ontario Renal Network is to improve the early detection of CKD and delay the progression to end stage renal disease, while improving access to care and nephrology services for those living with more advanced CKD. 
The next slide is going to introduce the definition of chronic kidney disease. 

4. What is Chronic Kidney Disease? According to KDIGO CKD Guidelines, 2012
This definition that you see before you is from the 2012 KDIGO chronic kidney disease guidelines. KDIGO stands for Kidney Disease Improving Global Outcomes and it is an international organization that produces guidelines on chronic kidney disease every few years. 
Chronic kidney disease is defined as abnormalities of kidney structure or function present for greater than three months with implications for health. The key point of this sentence is you have to have these abnormalities for at least three months in order to make a diagnosis of chronic kidney disease. I'll speak more on this in detail a little later on. 
The thing about the KDIGO CKD guidelines is that they really do not target primary care providers. These guidelines were mainly written for nephrologists or kidney specialists and so part of this talk is to clarify what these guidelines actually mean for primary care providers. 
Let’s take a look at the criteria for CKD. The first criteria talks about albuminuria, which means protein spilling into the urine. If you notice in brackets, there's two different values that are given for albuminuria. This begs the question, should you be ordering a 24 hour urine on patients that you suspect have chronic kidney disease or is just okay to order a urine ACR, which stands for albumin/creatinine ratio, when you're looking to diagnose chronic kidney disease. This isn't clear from this slide. 
The second point is urine sediment abnormalities. So does this mean you have to order a urine sample on every patient that you suspect has chronic kidney disease? This question will also be answered in a few slides. 
The next criteria is electrolyte and other abnormalities due to tubular disorders. Again, does this mean we should be ordering electrolytes on every patient we suspect to have chronic kidney disease? 
It continues to list other factors such as abnormalities detected by histology, which usually occurs with a kidney biopsy, structural abnormalities detected by imaging (for example a renal ultrasound), and finally a history of kidney transplantation. 
But to summarize, it is unclear from this list which tests a primary care provider should order when they're suspecting chronic kidney disease. 
The second criteria for chronic kidney disease is a decreased GFR or glomerular filtration rate. This is pretty straightforward. A GFR of less than 60ml/min, by definition, is chronic kidney disease, if the result repeated in three months is still abnormal. Again, the next few slides will clarify exactly how to diagnose chronic kidney disease in the primary care setting.

5. GFR Categories in CKD
This next slide focuses back on GFR, which was referred to in the previous slide. If you notice there are 6 categories of chronic kidney disease based on GFR. What's important here is that in isolation, a GFR greater than 60 is not considered chronic kidney disease. So patients that fall into stages 1 and 2 based on GFR alone, do not have CKD. 
For primary care purposes, focusing on stages 3a and 3b is very important. In this situation, the GFR result, or estimated GFR which is the blood test that you order on patients, that falls between 30 and 59 is considered chronic kidney disease. The majority of patients in primary care that you diagnose with chronic kidney disease, based on the GFR level, will fall into these two stages. The information from this talk will guide you on how to manage these patients moving forward.
If a patient has a GFR less than 30ml/min, which puts them in CKD stages 4 and 5, they have a more advanced form of chronic kidney disease and should be referred to a nephrologist for consultation.
KDIGO CKD Guidelines, 2012

6. Albuminuria Categories in CKD
This next slide talks about albuminuria, which was also referred to in the KDIGO definition of CKD. 
If a patient has isolated albuminuria consistent over three months, that patient can also have CKD regardless of their eGFR value. In this situation, KDIGO defines CKD based on albuminuria when you have a urine ACR, an albumin/creatinine ratio, greater than 3mg/mmol. This represents the A2 category. 
It's also important to know that on this slide there are three different values for albuminuria. One is a value based on a 24 hour urine collection, and the other two have different units - one is defined as mg/mmol and the other is defined as mg/gram. For the purposes of primary care practice, it is most important to emphasize that the test you should order to diagnose chronic kidney disease is a urine ACR or albumin/creatinine ratio which is the middle unit shown here in mg/mmol. 
It is not recommended to order a 24 hour urine in the primary care setting for two reasons. First, a urine ACR is a much easier test that can be done with the patient in your office or at a lab, and does not require a 24 hour collection of urine which is a more onerous task for a patient. Secondly, the interpretation of a 24 hour urine is not straightforward and patients often do not follow instructions properly when they are asked to do it. Therefore, it is recommended to leave that test up to the nephrologist should your patient require consultation at some point and have the nephrologist explain in detail why that test in necessary and how to follow the instructions properly. 
The categories for albuminuria for chronic kidney disease by KDIGO are defined here. There will be more information to clarify the significance of the urine ACR result later in this talk.
To summarize, in isolation, if there are two values of urine ACR greater than 3mg/mmol over a three month period, the patient has chronic kidney disease. 

7. Stages of Diabetic Nephropathy by Level of Urinary Albumin Level
This next slide comes from the Canadian Diabetes Association, and it also speaks to albuminuria.
What's important to notice here is that this slide has a cut-off of 2mg/mmol to define chronic kidney disease in isolation when you're ordering a urine ACR. This result is different from KDIGO which was mentioned in the previous slide as having a cut-off of 3mg/mmol. The Ontario Renal Network KidneyWise Clinical Toolkit uses the cut-off of 3mg/mmol to define chronic kidney disease based on albuminuria, as opposed to the 2mg/mmol as defined by the Canadian Diabetes Association. The main reason for this has to do with uncertainty about the accuracy of the urine ACR test at lower levels of albuminuria, coupled with concerns about over diagnosis and labeling patients unnecessarily with CKD. It is important to note that aside from this latter point, the information regarding management of patients with diabetes and CKD in the KidneyWise Clinical Toolkit (which will be discussed in detail later in this talk) is concordant with the Canadian Diabetes Association guidelines.
Canadian Diabetes Association 2013

8. Why Should CKD Be Important to Primary Care?
~ 90% of CKD cases are at low risk of progression and can be followed by a Primary Care Provider (e.g. family physician, nurse practitioner)
Early identification and treatment can prevent/delay ESRD
Comorbid cardiovascular disease risk reduction/management (e.g. DM, CAD/CHF)
Referral of patients at increased risk of progression to ESRD to nephrology
This next slide talks about why chronic kidney disease should be important to primary care. This is an important thing to discuss, considering the amount of information that primary care providers, both family physicians and nurse practitioners, need to know in order to deal with their patients on a day-to-day basis.
With many different chronic diseases competing for the time of a primary care provider, it is important to emphasize here why chronic kidney disease should also be a priority within primary care.
For starters, 90% of patients that you diagnose with chronic kidney disease will be at a low risk for progression to end stage renal disease and can be followed and managed by primary care providers, either family physicians or nurse practitioners, depending on where you work in Ontario.
Secondly, early identification of patients which chronic kidney disease and early intervention can prevent or delay the progression to advanced chronic kidney disease or even end stage renal disease. Remember that patients that end up with end stage renal disease, or stage 5 CKD, based on the eGFR categories that was referred to earlier in this lecture, may need renal replacement therapy, which will consist of either dialysis or renal transplant. The goal of primary care should be to try and prevent these situations from happening with their CKD patient in order to keep their disease stable.
Furthermore, primary care providers are very proficient at managing co-morbid cardiovascular diseases such as diabetes, coronary artery disease and congestive heart failure, and there is a direct correlation between cardiovascular disease and chronic kidney disease. So for all of the patients that are diagnosed with chronic kidney disease, it is very important to manage their cardiovascular risk factors.
Finally, there are going to be some CKD patients who progress that will require consultation with a nephrologist. It is very important for primary care providers to identify these patients early in order to get them access to nephrology and get the extra care that they require to manage the complications of advanced CKD and potentially prepare them for end-stage renal disease. 

9. Why Develop a CKD Clinical Tool for Primary Care?
CKD resources required based on feedback from:
2012 PCP needs assessment
Respondents were interested in improving their CKD knowledge
Access to reference tools/ decision aids centered on evidence-based clinical practice guidelines was ranked highly
2013 environmental scan
Completed to review clinical toolkits available to PCPs
As a result, a gap in CKD resources for PCPs became apparent
In response, ORN KidneyWise Clinical Toolkit created
This next slide talks about the history behind developing the KidneyWise Clinical Toolkit for primary care.
In 2012, the Ontario Renal Network did a primary care provider needs assessment in the area of chronic kidney disease. The respondents, who were primary care providers, reported back to the Ontario Renal Network that they were interested in improving their knowledge of chronic kidney disease. They specifically asked for access to reference tools and decision aides that were centered on evidence based clinical practice guidelines for CKD. 
In 2013, after analyzing the above data, the Ontario Renal Network did an environmental scan to review which clinical toolkits or guidelines were available for chronic kidney disease targeted to primary care providers. This scan revealed that there was a significant gap, and in response, the Ontario Renal Network created the chronic kidney disease KidneyWise Clinical Toolkit for Primary Care, which we will now review.

10. Guidelines Referenced
Kidney Disease Improving Global Outcomes CKD Guidelines 2012
Canadian Hypertension Education Program Guidelines 2014
Canadian Cardiovascular Society Dyslipidemia Guidelines 2012
Canadian Diabetes Association Clinical Practice Guidelines 2013
The KidneyWise Toolkit was developed using a disciplined approach. Production of the algorithm commenced in mid-2013, and was adapted from a publication on a study looking at nephrology referral patterns that was conducted at The Ottawa Hospital (Akbari et al., 2012).
A literature review of guidelines (Kidney Disease Improving Global Outcomes CKD Guidelines 2012, Canadian Hypertension Education Program Guidelines 2014, Canadian Cardiovascular Society Dyslipidemia Guidelines 2012, and Canadian Diabetes Association Clinical Practice Guidelines 2013) was completed.
Based on the aforementioned guidelines and soliciting feedback from expert nephrologists and PCPs, additional content was added using an iterative process. Production of the referral form began in 2014 and underwent a similar approach as the algorithm. All components of the toolkit have been vetted and endorsed by nephrology and primary care leaders within Ontario and across Canada.

11. KidneyWise Clinical Toolkit
Clinical Algorithm that helps with identification, detection, and management of patients with CKD and guidance on which patients may benefit from referral to a nephrologist
Evidence Summary that offers further clinical detail regarding the algorithm content, including references to clinical guidelines that were used in the development of the toolkit
Outpatient Nephrology Referral Form that provides referral guidance by outlining clinical scenarios that would require consultation with a nephrologist along with the appropriate investigations that should accompany the referral
This next slide outlines the various components of the KidneyWise clinical toolkit for primary care.
The first part of the toolkit consists of a clinical algorithm that helps with the identification, detection and management of patients with chronic kidney disease, and it also guides which patients may benefit from referral to a nephrologist. I will be going through this algorithm in detail in the next few slides. 
There is also an Evidence Summary that offers further clinical details regarding the algorithm content, including references to clinical guidelines that were used in the development of the Toolkit. This Evidence Summary is available online and can be read in detail after you finish watching this presentation.
Finally, we've created an Outpatient Nephrology Referral Form that not only provides referral guidelines by outlining clinical scenarios that would require consultation with a nephrologist, but it also suggests appropriate investigations that should accompany each referral. This Outpatient Nephrology Referral Form is also available on our website and can be incorporated into electronic medical records for ease of use in primary care practices.  

12. Clinical Algorithm
This next slide gives a snapshot of the clinical algorithm associated with the KidneyWise Clinical Toolkit. I am now going to breakdown each part of this algorithm and talk about it detail.
To note, there are three parts of this algorithm: identification, detection and management of chronic kidney disease. 

13. Clinical Algorithm – Identify
This next slide focuses on identification. There are three groups of patients that have been identified as being at elevated risk for chronic kidney disease. These three categories of patients are those with hypertension, those with diabetes and patients aged 60 – 75 years old with cardiovascular disease that includes coronary artery disease, congestive heart failure, stroke or peripheral vascular disease.
Regardless of age, hypertension and diabetes are the most common risk factors for CKD. It is also important to note that the presence of cardiovascular disease alone without co-morbid hypertension and/or diabetes is not only less common, but as an independent risk factor, it is not as significant a predictor of CKD. Once a patient turns 60 years of age, their risk of developing CKD, by virtue of age alone, increases significantly. However, to avoid over-screening while being mindful of health care resource utilization, the ORN modified this age risk factor to include patients with cardiovascular disease. This not only will reduce the number of CKD screening tests ordered, but it will still capture patients with cardiovascular disease who may not have associated hypertension or diabetes – an important population to test for CKD. The ORN chose a cut-off of age 75 years and older to emphasize caution when considering screening elderly patients for CKD who may have a limited life expectancy. It is likely in these patients that a new diagnosis of CKD will not have a significant impact on their mortality risk.
It is also important to note that this identification category is not extensive. There are other categories that you may read about that also put patients at risk for chronic kidney disease. For example, family history of end stage renal disease, as well as certain systemic conditions like lupus, are also associated with a higher risk of CKD. However, the ORN felt they wanted to identify the categories related to population health that were most relevant within primary care, and therefore, it is the above three categories that we added to the Toolkit.

14. Clinical Algorithm – Detect
The next category is detection. I will use the next slide to explain this in more detail.

15. What Tests Should Be Ordered? - Detect
Creatinine/ eGFR
Measure of kidney function
Urine for ACR (albumin to creatinine ratio)
Measure of kidney damage/injury (protein excreted in urine)
Important Note: CKD detection should be done in the absence of acute inter-current illness
Low eGFR in such scenarios may reflect acute kidney injury and require more rapid evaluation
There are two tests that should be ordered in order to detect chronic kidney disease. 
The first test is a creatinine, which also usually comes with an eGFR, or estimated Glomerular Filtration Rate, in most labs in Canada. This is a measure of kidney function. 
The second test that should be ordered for all the patients identified as having risk factors for chronic kidney disease, is a urine for ACR, or urine for albumin/creatinine ratio. This is a measure of kidney damage or injury, and as mentioned earlier, measures the amount of protein excreted in the urine. 
These are the only two tests that the ORN recommends to diagnose patients with CKD who are at elevated risk. It is also important to note that when testing for patients who are at risk for chronic kidney disease, it should be done in the absence of an acute inter-current illness. For example, it would not be advisable to try and diagnose chronic kidney disease in a patient who presents to your office with dehydration or volume depletion. The reason for this is that there can be low eGFR values in such scenarios that might be reflecting an acute reversible kidney injury, or AKI, as opposed to chronic kidney disease, and this AKI will require a more rapid evaluation and a different work up.

16. If The Results Are Abnormal, When Should One Repeat The CKD Screening Tests? - Detect
Assuming no inter-current illness:
If eGFR < 60, repeat in 3 months or sooner if clinical concern
If urine ACR ≥ 3, repeat 1-2 more times over the next 3 months
This next slide talks about what to do with the results. 
So if you order an eGFR and a urine ACR on a patient that you've identified as being at elevated risk for chronic kidney disease, based on the KidneyWise algorithm, the first result has to be abnormal in order to identify patients that may have CKD.
So assuming that they do not have an acute inter-current illness, if your first test of an eGFR is less than 60ml/min, you have to repeat the test in three months in order to make the diagnosis of chronic kidney disease. The same goes for a urine ACR. If the urine ACR is greater or equal to 3gm/mmol, you also have to repeat that in three months in order to determine if a patient has chronic kidney disease. Specifically for the urine ACR, if you repeat the test in three months and it's normal, you would then be recommended to repeat it again two weeks later, because you need at least 2 out of 3 abnormal values to make the diagnosis of chronic kidney disease using urine ACR.
With respect to the eGFR, if you get an eGFR result that is abnormal, which is defined as less than 60ml/min, but it is a surprising result, or a result that you weren't expecting, you may not want to wait three months in order to repeat the test. For example, if you had a baseline eGFR that was ordered in the past, having nothing to do with diagnosing a patient with chronic kidney disease, and then when you screen this patient for CKD due to their risk factors, the eGFR result is significantly lower than the baseline eGFR, you might want to consider an acute process or an acute kidney injury that's causing this result.
The main point of this slide is that you still want to use your clinical acumen to determine if your first result that is abnormal could wait three months to be repeated, or if a more urgent work-up is required.

17. Is One Test Result Enough To Diagnose CKD?
No – CKD is defined as a persistent abnormality for at least 3 months
Always consider reversible causes prior to re-testing (e.g. recent treatments with NSAIDs, herbal remedies, recent use of contrast dye for diagnostic imaging, BPH/urinary retention, volume depletion)
Renal ultrasounds are not recommended as a routine test to diagnose CKD, but are appropriate when ruling out a AKI.
So as a reminder, if you get a first result eGFR or urine ACR that is abnormal, one test is not enough to diagnose chronic kidney disease. The abnormal results need to persist for at least three months and have to be repeated at that time in order to make the diagnosis. If however, the first urine ACR result or eGFR result is concerning to you, always consider reversible causes prior to re-testing. For example, consider the following possibilities:
is the patient using over the counter NSAIDs, or non-steroidal anti-inflammatory drugs, that might be affecting the test results;
is the person using a herbal remedy that might be affecting the results;
has the patient recently gone for a diagnostic imaging test and the use of contrast dye has affected the patient’s renal function;
has the patient recently suffered from a gastrointestinal illness, resulting in vomiting and/or diarrhea that can affect these test results;
and finally, does the patient have an enlarged prostate or are they suffering from urinary retention.
If any of these are suspected, you should be repeating these tests earlier than three months to rule-out an acute kidney injury.
It is also important to mention again that renal ultrasounds are not recommended as routine tests to diagnose chronic kidney disease. This is due to the fact that often the results of these tests do not help with the diagnosis, and interpretation results can lack consistency. However, if a renal ultrasound is an appropriate test to rule-out an acute kidney injury, as mentioned above, then ordering this test is absolutely appropriate. 

18. Clinical Algorithm – Detect
This next slide talks about how to make the diagnosis of chronic kidney disease at the three month mark. I will be breaking this down into three boxes: Box A, Box B, and Box C, as illustrated by this diagram.

19. Interpreting The Results Three Months Later - Detect
Patient does not have CKD
Follow-Up Recommendations:
Re-test annually for patients with diabetes, less frequently unless clinical circumstances dictate more frequent testing
Avoid labeling a patient with CKD unless confirmed
The first box we will review is Box C. So just to recap, this is where you have a patient that you have identified as high risk for chronic kidney disease based on the risk factors that were talked about earlier. You have then gone ahead and ordered an eGFR and a urine ACR, and these initial results have either both come back abnormal or one of them has come back abnormal. There was no inter-current illness present and you are not concerned about any other acute kidney injury.
You have now repeated the tests 3 months later and the results have both come back normal. The eGFR is now greater than 60ml/min and the urine ACR is less than 3mg/mmol. As a reminder, if your first urine ACR was abnormal, and now you have a normal urine ACR, please repeat the urine ACR two weeks later just to confirm it continues to be normal. In this scenario, the patient does not have chronic kidney disease.
The key question now is, when do you follow-up on another test for this patient who remains at high risk for chronic kidney disease? This answer is also somewhat arbitrary. If you look at the KDIGO guidelines, they give very detailed information on when to follow-up a patient who is at high risk for chronic kidney disease. The Ontario Renal Network wanted to simplify this for primary care providers given how busy your schedules are, and we have decided the following: for patients with diabetes, you should retest them for chronic kidney disease at least annually; for all other patients, repeating the test for CKD can occur less frequently, unless clinical scenarios dictate more frequent testing. Although this is not clear cut, we leave the decision up to you depending on the relationship you have with your patient. Again, I want to emphasize that you want to avoid labeling a patient with chronic kidney disease, unless you confirm that result three months after the original abnormal test. 

20. Interpreting The Results Three Months Later - Detect
Patient has CKD
Work-Up: Check urine R&M, electrolytes
Follow-Up Recommendations:
Serial following of eGFR and urine ACR to monitor for progression
Every 6 months once diagnosis made
Annually once eGFR is stable for 2 years
This next slide represents Box B. Again, just as a reminder, this is where you have a patient that you have identified as being at high risk for chronic kidney disease; you have ordered a urine ACR and eGFR, and either one or both values were abnormal. You are now repeating the test three months later to determine if the patient has a true diagnosis of CKD. 
In this situation, either the eGFR comes back between 30 & 59ml/min and/or the urine ACR comes back between 3 & 60 mg/mmol. In this scenario, the patient has chronic kidney disease. The first thing you should do is discuss this diagnosis with your patient, and then you should order two more investigations: a urine for routine and microscopy or R+M, and electrolytes.  
The urine R+M is ordered to look for microscopic hematuria, as well as red blood cell casts that might indicate other forms of nephropathy, such as glomerulonephritis. Electrolytes are ordered to pick up any abnormality that may need to be addressed urgently, such as high potassium or hyperkalemia. If you have any questions about the results of these tests, if they come back abnormal, you should consult your local nephrologist for assistance. 
Furthermore, these patients need ongoing follow-up in order to monitor for any progression of their chronic kidney disease. Serial follow-up of eGFR and urine ACR is required every six months after the diagnosis is made. If the patient’s eGFR value is stable for a two year period, you can decrease the frequency of monitoring to once a year. 

21. Follow-Up Recommendations - Detect
During follow-up, refer to a nephrologist if:
eGFR < 60 and decline ≥ 5ml/min within 6 months (confirmed on repeat testing within 2-4 weeks), or
eGFR < 30 or ACR > 60, or
eGFR <45 and urine ACR between 30 and 60 on 2 occasions, at least 3 months apart
This next slide talks about what to look for as you're monitoring the patient every six months, or every year, depending on the stability of their chronic kidney disease defined by their eGFR level. The following criteria listed here should be identified as reasons to refer to a nephrologist. For example, once a patient has an eGFR less than 60ml/min, and that eGFR declines by greater than 5ml/min within a six month period, it means this patient is at higher risk of progression towards advanced chronic kidney disease and should be seen in consultation by a nephrologist. This result should also be confirmed weeks afterwards in order to make sure there was no lab error. Please take a moment to review the rest of this list.
I will talk about some of the management steps you can follow in order to help prevent CKD progression, but should a patient meet any of these criteria, they should be referred for nephrology consultation.

22. Interpreting The Results Three Months Later - Detect
Patient has CKD
Refer patient to a nephrologist
Work-Up Recommendations:
Consider ordering & sending the following with referral:
Urine R&M, electrolytes (for albuminuria)
Urine R&M, electrolytes, CBC, serum calcium, phosphate, albumin, PTH (for low eGFR)
Don’t lose relationship with your patient!
This next slide is Box A. The final box to consider when you're making a diagnosis of chronic kidney disease. Just as a reminder this is when you have a patient that was identified as high risk for CKD and their original eGFR and/or urine ACR test was abnormal. You have now repeated the test three months later and their eGFR result is less than 30ml/min, and/or their urine ACR result is greater than 60mg/mmol. In this situation, the patient has chronic kidney disease, and mentioned on the previous slide, because these values are significantly abnormal, they should be referred to a nephrologist. 
The other important thing to take into account with this slide is that when you are referring a patient for nephrology consultation, please do not loose the relationship with your patient. Just because the nephrologist is going to help you manage a patient with advanced or progressive chronic kidney disease, it should be considered a shared care model. The primary care provider is still responsible for the management of these patients’ overall health needs. It is also important to work together and communicate with your consulting nephrologist in order to give your patient the best care with respect to their CKD.

23. Clinical Algorithm – Manage
The next section in the KidneyWise Clinical Algorithm for CKD focuses on management.
I will now take you through the three categories.
The first category will focus on how to modify cardiovascular risk factors, then I’ll talk about minimizing further kidney injury, and finally I’ll discuss implementing measures to slow the rate of chronic kidney disease progression. 

24. Clinical Algorithm – Manage
This first slide talks about implementing measures to modify cardiovascular risk factors.
Primary care providers are well suited to counsel their patients on how to modify their lifestyle by incorporating regular exercise and a healthy diet, as well as quitting smoking which puts you at risk for cardiovascular disease.
In terms of lipid management, the guidelines for chronic kidney disease differs slightly from the 10-year Framingham risk assessment tool that most of you probably use in your practice. The following CKD patient categories are at higher risk for cardiovascular disease and would benefit from statin therapy.
To summarize, if a patient with chronic kidney disease has diabetes, and they are older than 18, it is recommended they start taking a statin. A discussion about pharmacotherapy, including side effects, should then take place with the patient. 
If a patient does not have diabetes but has chronic kidney disease, and they're older than age 50, they should also be recommended to start a statin. 
And finally, for patients without diabetes but who have chronic kidney disease, that are between the ages of 18 & 49, and also have known coronary disease, a prior stroke, or their 10-year Framingham risk is greater than 10%, they should also be recommended for statin treatment.
For patients with chronic kidney disease who also have diabetes, it is important to reach the appropriate target hemoglobin A1C levels as defined by the Canadian Diabetes Association guidelines. Please refer to these guidelines for further information.  

25. Correlation between CKD and CVD
This next slide just shows the correlation between chronic kidney disease and cardiovascular disease. 
If you notice, the x-axis represents eGFR and the y-axis represents the age standardized rate of cardiovascular events. As the eGFR decreases across the x-axis, the number of cardiovascular events in the y-axis increases. This emphasizes that patients with chronic kidney disease need to be managed in terms of their cardiovascular risk factors in order to reduce their chance of having a cardiovascular event.
Go,A et al. NEJM 2004;351:

26. Clinical Algorithm – Manage
This next slide regarding the management of CKD focuses on how to minimize further kidney injury. As mentioned earlier, please advise all patients with chronic kidney disease to avoid nephrotoxic medications, such as Nonsteroidal Anti-inflammatory Drugs or NSAIDs. As well, if patients are going for diagnostic imaging tests and require intravenous or intra-arterial contrast, please make sure the radiologist knows that they have chronic kidney disease as sometimes using contrast in this population is contraindicated. If contrast dye is necessary for certain diagnostic tests, please consider reminding the patient to hydrate orally with fluids and to withhold diuretic medication, where applicable, prior to the test being done. 
Furthermore, in our evidence summary of the KidneyWise Clinical Toolkit, we have listed the Sick Day Medication list from the Canadian Diabetes Association guidelines. This list of medications are to be avoided in patients with chronic kidney disease if they get sick - specifically, illnesses that cause vomiting, diarrhea, and volume depletion. Please refer to the Evidence Summary of the Clinical Toolkit for more information.
And finally, for patients with chronic kidney disease to whom you're prescribing medications, regardless of the medical indication, please remember to check whether the dose of that medication needs to be adjusted because of their decreased renal function. 
Don’t forget to adjust dose of renally excreted medications!

27. Clinical Algorithm – Manage
Blood Pressure
Urine ACR
If > 130/80 – treat HTN based on CHEP
If > 3 - Treat with ACEI or ARB (but watch for hypotension)
If > 140/90 – treat HTN based on CHEP
If > 30 AND BP > 140/90 – Treat with ACEI or ARB DM
This final management slide for patients with chronic kidney disease in the primary care setting will focus on implementing measures to slow the rate of CKD progression.
This slide will focus on blood pressure management as well as management of an elevated urine ACR should it exist with the CKD patient.
Let's start with blood pressure. For patients with chronic kidney disease, who also have diabetes, their blood pressure should be targeted to be less than 130/80 as per the Canadian Hypertension Education Program or CHEP guidelines. If a patient with CKD does not have diabetes, then their blood pressure should be targeted to be less than 140/90. 
In terms of urine ACR, if a patient has chronic kidney disease and they have diabetes, and their urine ACR is greater than 3mg/ml, then they should be started on an ACE inhibitor or an ARB
Please note that for patients with chronic kidney disease, and diabetes, and an elevated urine ACR, it is recommended to use either an ACE inhibitor or an angiotensin receptor blocker to treat their elevated urine ACR regardless of their blood pressure measurement. However, if this diabetic patient with chronic kidney disease and an elevated urine ACR already has their blood pressure at target, or lower than target, one must use an ACE inhibitor or ARB cautiously in order to prevent a patient from developing orthostatic hypotension.
Orthostatic hypotension can lead to falls, as well as fractures, and it is important to weigh the risks and benefits of treating a diabetic patient with CKD for their elevated urine ACR before starting pharmacotherapy.
If a patient who has chronic kidney disease, does not have diabetes, and has an elevated urine ACR greater than 30mg/mmol, in addition to their blood pressure being above target of 140/90, then is recommended to start treatment with an ace inhibitor or an ARB. Please note that in this scenario, you are choosing the ACE inhibitor, or ARB in order to treat the patient’s hypertension, and this class of anti-hypertension drugs is preferred over others due to the added benefit of treating the elevated urine ACR that is above 30mg/mmol.
If you have a CKD patient without diabetes, who does not have an elevated ACR greater than 30mg/mmol, but is still hypertensive, you have other choices you can use as a first line therapy for high blood pressure as per the CHEP guidelines.
You may still in fact choose an ACEI or ARB if the patient has other clinical indications (for example known coronary artery disease or congestive heart failure). Please refer to those guidelines for further information. 
Non-DM
Lytes/Cr 2 weeks after starting ACEI or ARB

28. Outpatient Nephrology Referral Form
This slide is a snapshot of the KidneyWise Outpatient Nephrology Referral Form.
This form can be accessed via our website, which I will talk about at the end of this presentation, and it can also be incorporated into an electronic medical record for ease of use.
Please notice the features of this nephrology referral form. The top part of the form has a section on patient information that can either be completed electronically, or by hand. Alternatively, your staff could produce a patient label or sticker to populate that section.
In terms of recommendations and reasons for referral, we put tick boxes beside the most appropriate reasons to refer to nephrology – most of which were already mentioned earlier during this presentation. There's also an area where you can put additional comments should you request a consultation for another reason. 
We tried to include common co-morbid conditions on the form that could simply be checked off. Obviously providers could attach a separate list of relevant past medical history if applicable.
In terms of the lab values, these can be attached to the referral form as a separate page, or they can be pre-populated electronically using your EMR.
The medication list can also be entered on the face of this page or attached separately.
And finally, the bottom part of the form just requires a signature, the referring practitioner's information and billing address.

29. Recommended Reasons for Referral
This next slide focuses again on the reasons to refer to nephrology. Most of these reasons have already been mentioned earlier in this talk. The reasons that were not mentioned, as they may not relate to chronic kidney disease, include: a metabolic work-up for recurrent renal stones, and treatment resistant hypertension.
So the Outpatient Nephrology Referral Form is not just for CKD patients, and we are really hoping that the majority of primary care providers in Ontario use this form to keep nephrology referrals consistent and appropriate. We are also speaking with our nephrology colleagues to make sure they are accepting the form when it is sent to them. 
Again, most patients who are at low risk for progression to advanced or end-stage renal disease can be managed by primary care providers, and do not require nephrology referral. This referral form is just a guide and a list of the most appropriate indications for a referral to nephrology but it's still expected that the primary care provider play a large role in managing their patients with CKD. 
Most patients with non-progressive/ low-risk CKD can be managed by primary care providers!

30. Conclusions
CKD testing should only be applied to patients at high risk of CKD and in the absence of acute intercurrent illness – Identification
eGFR and urine ACR are the tests of choice – Detection
Most cases of CKD in primary care are low-risk and can be managed by PCPs – Management
Refer to nephrology as appropriate
The KidneyWise Clinical Toolkit will make CKD care easier for PCPs and empower us to improve patient outcomes
So, In conclusion, chronic kidney disease testing should only be applied to patients at high risk of chronic kidney disease and in the absence of acute inter-current illness. This is known on the KidneyWise Clinical Algorithm as identification. 
eGFR and urine ACR are the tests of choice for patients at high risk for chronic kidney disease and this is referred to as ‘detection’ on the KidneyWise Clinical Algorithm. 
Most cases of chronic kidney disease in primary care are low risk for progression to advanced CKD and can be managed exclusively by primary care providers; this is known as management on the KidneyWise Clinical algorithm. But please remember to refer to nephrology as appropriate as outlined on the outpatient nephrology referral form. The main reason for referral is to identify patients at high risk of progression that may require further management by the nephrologist. 
Finally, the KidneyWise Clinical Toolkit will make chronic kidney disease management easier for primary care providers and will empower all of us to improve patient outcomes related to chronic kidney disease.

31. Where can I find it? Website: kidneywise.ca App:
The KidneyWise clinical Toolkit is available on the Ontario Renal Network website at kidneywise.ca
There is also a link to download our interactive KidneyWise app available for smartphones and tablets. Please try out the app. It is very practical, reviews all of the content of this presentation and can be used while interacting with your CKD patients in clinic. 
If you have any questions about the KidneyWise Toolkit, or about the content of this lecture, please us. Our address is:

32. Feedback
Thank you
Contributors
Finally I want to thank you for the time you took to watch this presentation,
I also want to thank my colleague Dr. Scott Brimble for helping to develop this presentation and the KidneyWise Toolkit. Dr. Brimble is the provincial lead for the Early Detection and Prevention of Progression Program at the Ontario Renal Network. He is also an Associate Professor in the Department of Medicine at McMaster University and a practicing academic nephrologist. 
This ends the KidneyWise CKD Clinical Toolkit presentation.
Dr. Scott Brimble, MD, MSc, FRCPC
Provincial Lead, Early Detection and Prevention of Progression, ORN
Associate Professor, Dept. of Medicine, McMaster University
Dr. Allan Grill, MD, CCFP, MPH
Provincial Primary Care Lead, ORN
Assistant Professor, Dept. of Family & Community Medicine, University of Toronto