Renal Physicians Association Clinical Practice Guideline: Appropriate Patient Preparation For Renal Replacement Therapy:

Monitoring Anemia Regularly

If a patient has GFR ≤ 30 ml/min per 1.73 m², then s/he should have his/her hemoglobin checked at least every three months. (Grade C)

Workup of Anemia

If a patient has GFR ≤ 30 ml/min per 1.73 m² and a hemoglobin < 12 g/dl if a woman, and < 13 g/dl if a man, then s/he should undergo a complete work-up for anemia including iron studies. (Grade B)

Treating Iron Deficiency

If a patient has GFR ≤ 30 ml/min per 1.73 m², and if iron deficiency is identified, then s/he should be treated. (Grade C)

Treatment with Erythropoietin or Erythropoietin Analogue

If a patient has GFR ≤ 30 ml/min per 1.73 m², and remains anemic despite appropriate evaluation and iron therapy, then s/he should be treated with erythropoietin or analogue. (Grade B)

Monitoring BP for Those Receiving Erythropoietin or Erythropoietin Analogue

If a patient has GFR ≤ 30 ml/min per 1.73 m², and is receiving erythropoietin or analogue, then s/he should have his/her BP checked with each dose. (Grade C)

Monitoring for Metabolic Acidosis

If a patient has GFR ≤ 30 ml/min per 1.73 m² then s/he should be monitored for acidosis (serum bicarbonate concentration) at least every three months. (Grade C)

Correcting Metabolic Acidosis

If a patient has a GFR ≤ 30 ml/min per 1.73 m² then his/her chronic metabolic acidosis should be corrected to a serum bicarbonate ≥ 22 mmol/L. (Grade C)

Monitoring Calcium, Phosphorus, and iPTH

If a patient has a GFR ≤ 30 ml/min per 1.73 m², then s/he should have his/her serum calcium and phosphorus measured at least every three months, and iPTH levels measured at least once, (Grade B) AND if calcium and/or phosphorus levels are abnormal, iPTH should be monitored at least every three months. (Grade C)

Treating HPTH and/or Hyperphosphatemia

If a patient has GFR ≤ 30 ml/min per 1.73 m², and if iPTH > 100 pg/ml (or > 1.5 times the upper limit of normal for each assay used), OR serum phosphorus > 4.5 mg/dl then s/he should be placed on a low phosphorus diet (< 800–1000 mg/d) for one month, and phosphorus levels should be re-checked, regardless of phosphorus or iPTH levels. (Note: a low phosphorus diet implies a low protein diet.) If serum phosphorus is still > 4.5 mg/dl, then phosphate binder should be started (Grade B) AND iPTH levels should be monitored every three months following the initiation of therapy, whether phosphorus is controlled or not. (Grade B)

Managing Decreased Vitamin D Levels (Vitamin D Insufficiency)

If a patient has GFR ≤ 30 ml/min per 1.73 m² and if iPTH > 100 pg/ml (or 1.5 times the upper limit of normal for each assay used), then measure 25(OH) vitamin D; AND if 25(OH) vitamin D is decreased (serum levels < 30 ng/ml) then s/he should receive vitamin D₂ 50,000 units orally every month for 6 months. (Grade C)

Managing Hypocalcemia

If a patient has GFR ≤ 30 ml/min per 1.73 m² and corrected serum calcium is < 8.5 mg/dl (using a normal reference range of 8.5 to 10.5 mg/dl) after phosphorus issues are addressed, then s/he should receive elemental calcium 1 g/d between meals or at bedtime. (Grade C)

Treating Refractory HPTH

If a patient has GFR ≤ 30 ml/min per 1.73 m² and iPTH remains > 100 pg/ml (or > 1.5 times the upper limit of normal for each assay used) after 3 months of previously recommended interventions, then s/he should receive oral vitamin D therapy with 0.25 mcg/d of calcitriol (Grade C) or alfacalcidol 0.25 mcg/d, to a maximum of 0.5 mcg/d.

Monitoring BP

If a patient has GFR ≤ 30 ml/min per 1.73 m², then his/her BP should be checked with every clinic visit (Grade A), which should be at least every three months. (Grade C)

Responding to Elevated BP

If a patient has GFR ≤ 30 ml/min per 1.73 m², and if BP is determined to be elevated (systolic > 130 mmHg OR diastolic > 80 mmHg), then s/he should receive encouragement and instruction to initiate therapeutic lifestyle changes (Grade C) and s/he should receive intensified antihypertensive therapy. (Grade B)

Treating with ACE Inhibitors and ARBs

If a patient has GFR ≤ 30 ml/min per 1.73 m² and hypertension, then s/he should receive an ACE inhibitor or an ARB as a first-line agent. (Grade C)

Monitoring Nutritional Status Regularly

If a patient has GFR ≤ 30 ml/min per 1.73 m², then his/her nutritional status should be monitored by measuring body weight and serum albumin every three months. (Grade B)

Managing Malnutrition

If a patient has GFR ≤ 30 ml/min per 1.73 m², and if body weight decreases unintentionally by more than 5% or serum albumin decreases by more than 0.3 g/dl or is < 4.0 g/dl (for Bromo-Cresol-Green assay, or 3.7 for Bromo-Cresol-Purple assay), then s/he should be evaluated for causes. If other causes are ruled out and cause is therefore determined to be CKD, then s/he should receive diet assessment and counseling by qualified and experienced personnel. (Grade C)

Initiating RRT Based on Nutritional Status

If a patient has GFR < 20 ml/min per 1.73 m², with evidence of malnutrition that does not respond to nutritional intervention in the absence of other causes of malnutrition, then s/he should begin RRT. (Grade C)

Monitoring for Dyslipidemias

If a patient has GFR ≤ 30 ml/min per 1.73 m², then she/he should be monitored for dyslipidemias; measurements should include triglycerides, LDL, HDL, and total cholesterol. (Grade B)

Evaluation for Secondary Causes

If a patient has GFR ≤ 30 ml/min per 1.73 m², and has dyslipidemia, then s/he should be evaluated for secondary causes including comorbid conditions and certain medications. (Grade C)

Treatment of Dyslipidemias

If a patient has GFR ≤ 30 ml/min per 1.73 m², LDL should be targeted to < 100 mg/dl; non-HDL cholesterol should be targeted to < 130 mg/dl; and fasting triglycerides ≥ 500 mg/dl should be treated. (Grade C)

Early Counseling about Modality of RRT

If a patient has GFR ≤ 30 ml/min per 1.73 m², modality of RRT should be discussed with him/her. (Grade B).

GFR as a Guide to RRT Timing

No recommendation can be made for initiating RRT based solely on a specific level of GFR. (Grade B).

Early Referral for Transplant Evaluation

If a patient has GFR ≤ 30 ml/min per 1.73 m² and is willing to have a renal transplant, then s/he should receive a transplant evaluation (Grade B), unless s/he has an unacceptable level of surgical risk or does not satisfy the United Network for Organ Sharing (UNOS) Ethics Committee criteria for transplant candidacy.

Preservation of Veins for Vascular Access

If a patient has GFR ≤ 30 ml/min per 1.73 m² and it has been determined that s/he will receive hemodialysis, veins suitable for placement of vascular access should be preserved. (Grade C).

Timing for Vascular Access Placement

If a patient has GFR ≤ 30 ml/min per 1.73 m², and it has been determined that s/he will receive hemodialysis, then s/he should be referred for surgery to attempt construction of a primary AV fistula. (Grade C).

Exercise

If a patient has GFR ≤ 30 ml/min per 1.73 m² and does not engage in regular physical activity, then s/he should receive counseling and encouragement to increase physical activity. If a patient is unable to walk or unable to increase fully mobile physical activity, then s/he should be referred to physical therapy or cardiac rehabilitation. (Grade B)

Evaluation, Education, and Encouragement

If a patient has GFR ≤ 30 ml/min per 1.73 m², then s/he should receive structured education regarding preparation for RRT. (Grade C)

Employment Counseling

If a patient has GFR ≤ 30 ml/min per 1.73 m² then s/he should be encouraged to maintain employment and be referred to vocational counseling per his/her preference. (Grade C)

Working Group