Healthcare CKD Protocol

Healthcare CKD Protocol

Patient Information

Date of Birth:    Gender:    MRN / ID:

Phone:    Alternate Phone:

Insurance Information

Policy Number:    Group Number:

Medical History & Baseline Assessment

eGFR (most recent):    Date of eGFR:    Urine ACR / PCR:

CKD Classification

CKD Stage (select all that apply): G1 (eGFR ≥90) G2 (eGFR 60–89) G3a (eGFR 45–59) G3b (eGFR 30–44) G4 (eGFR 15–29) G5 (eGFR <15)

Albuminuria category: A1 (<30 mg/g) A2 (30–300 mg/g) A3 (>300 mg/g)

Monitoring and Laboratory Orders

Baseline labs recommended (check and document recent values):

Recommended monitoring frequency: Every 3 months Every 6 months Annually

Treatment Plan and Orders

Blood pressure target: . Individualize based on comorbidities and risk of adverse events.

Antihypertensive therapy: ACE inhibitor or ARB unless contraindicated Diuretic as indicated for volume control Statin therapy per cardiovascular risk

Referral and Escalation Criteria

Refer to nephrology when any of the following apply (check all that apply):

Rapid decline in eGFR (>5 mL/min/1.73m2/year or as clinically significant) Persistent albuminuria A2/A3 despite therapy CKD stage G4–G5 or eGFR <30 mL/min/1.73m2 Uncontrolled hypertension despite multi-drug regimen

Nephrology referral placed:    Urgency:

Patient Education & Self-Management

Provide tailored education on CKD, medication adherence, dietary sodium/protein guidance, and signs of worsening kidney function. Document education delivered and materials provided.

Patient / Caregiver informed of plan: Yes    If caregiver present, name:

Advanced Care Planning & Dialysis Preparation

Assess need for advance care planning discussion, vascular access planning, and education about dialysis and transplantation for patients approaching ESRD. Document decisions and referrals.

Protocol Authority, Limitations, and Documentation

This protocol authorizes clinicians to implement the orders and monitoring described herein for patients meeting criteria. Clinical judgment supersedes protocol where individual patient circumstances warrant deviation. Document any deviations, rationale, and communication with consulting services in the medical record.

Confidentiality: Information gathered and recorded under this protocol is part of the patient's medical record and subject to applicable privacy rules. Only authorized personnel should access or share protected health information consistent with institutional policy and law.

Protocol Administration

Effective Date:    Next Review Date:    Expiration Date (if applicable):

Protocol exceptions must be approved by the approving authority and documented. Routine audits will assess adherence, patient outcomes, and need for modification.

Acknowledgment and Signatures

The undersigned attest that they have reviewed this CKD Protocol, that the content reflects current institutional standards of care for management of chronic kidney disease, and that they are authorized to implement and approve the protocol within their clinical responsibilities.

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