Monitoring the patient with chronic kidney disease -- my ABFM QI project criteria

Every three years I have to do a quality improvement project to maintain my family medicine board status.  This year I decided to focus on my patients with moderate chronic kidney disease. I have access to a report that identifies the patients of interest so all I need to do for the project is upgrade their care.

To do that I had to put together a list of things to do by reading the short "pocket card" version of the VA/DoD care guidelines (I'm too lazy to read the entire long thing). I then ran it past a friend who is a leading research nephrologist to comment on which of the guideline actions were really valuable.

I liked the result so much I'll share it here. The numbered items are what I took from the guidelines, the comments in () are his corrections, the comments in [] are my later thoughts. I think it's most interesting to read with both, I added emphases: 

As of Dec 2020:

1.       Measure urine alb/cr ratio yearly (sure in people with diabetes not on ace/arb)

2.       Measure Cr yearly (ok- not great evidence) [U/A, micro albumin, Iron]

3.       ACE/ARB for all but not both (if htn and/or microalbuminuria – or chf) [so implies measure for microalbuminuria along with yearly Cr]

4.       Oral iron therapy (if iron deficient, or starting epo) [so, contra guideline, not routinely, but implies check iron yearly?]

5.       If Hgb < 10 consult for erythropoietin (I’d wait till < 9 – no evidence for greater)

6.       DM

a.       Evaluate metform if CrCl < 40 (ok)

b.       SGLT-2 (empagiflozin, etc) inhibitor if stage 1-3 and DM (can go down to egfr of 30)

c.       GPL-1 agonist (liraglutide)  (no good evidence beyond sglt2) [contra guideline]

7.       If GFR < 60 then BP < 140/90 (I think this would be for most people)

8.       Do cystatin-C GFR one time (never unless paraplegic or loss of muscle mass – amputation) [contra guideline]

9.       If not Diabetic need at least one renal imaging study [I made this one up, but seemed to follow] (sure)

10.   Apply Kidney Failure Risk Calculator (Navdeep Tangri, MDCalc) (sure)

11.   Stage 3 and above: dietary consult

a.       Bicarbonate supplementation if metabolic acidosis (if bicarb < 18)

b.       Dietary sodium restrictions (yes – for all those with htn)

c.       Protein 0.6-0.8 g/kg/day (skip this one – good evidence – hard to do) [Curbsiders had recent podcast saying same]

12.   Stage 3 and above need a PTH measured (never measure pth in ckd unless hypercalcemia) [contra pocket card guideline so many a mistake in that]