Online clinical pathway for managing adults with chronic kidney disease

Around one-tenth of the adults in Canada are affected by chronic kidney disease (CKD), which is defined as estimated glomerular filtration rate (eGFR) less than 60 mL/min/1.73 m2.1 Early recognition of CKD is important, since timely implementation of lifestyle and pharmacological interventions can prevent it or slow its progression.2-4 Such interventions can also reduce the incidence of cardiovascular disease (CVD)5,6—the primary cause of death in these patients.7 However, patients with CKD are often not recognized and do not receive optimal treatment because of complexities in care and failure to disseminate best practices.8-10 The Kidney Disease Improving Global Outcomes (KDIGO) CKD clinical practice guidelines provide evidence for the evaluation and management of CKD.11 While clinical practice guidelines summarize evidence and provide recommendations, they are often difficult to apply in routine daily clinical activities. Clinical pathways are often derived from clinical practice guidelines but differ by providing more explicit and practical information about the sequence, timing and provision of interventions.12 A clinical pathway can be an effective tool to increase uptake of evidence-based health care by pharmacists and other primary care professionals in the community, who care for the majority of patients with CKD.13-15 Pharmacists in Canada have an expanding scope of practice; pharmacists can order laboratory tests, adapt new prescriptions, perform therapeutic substitutions, issue prescriptions for continuity of care and prescribe in emergency situations.16 In Alberta, pharmacists who have Additional Prescribing Authorization can prescribe at initial access or manage ongoing therapy based on their own assessment or in collaboration with another regulated health care professional.17 An integral part of pharmacists’ practice is working collaboratively and communicating with physicians and other health care providers.17 As pharmacists’ expanded scope of practice develops,16 tools such as the CKD Clinical Pathway (Figure 1) can assist pharmacists to implement evidence-based guidelines into their daily practice. This manuscript provides an overview of the clinical pathway for diagnosis, management and referral of adults with CKD and its potential clinical use for pharmacists. Figure 1 Overview of the adult CKD Clinical Pathway Development of the adult CKD Clinical Pathway The CKD Clinical Pathway is an online tool/guideline modeled after the successful National Institute for Health and Clinical Excellence (NICE) clinical pathways (http://pathways.nice.org.uk). It was developed by a team of stakeholders that included pharmacists, nephrologists, primary care physicians, nurses, other health care professionals, IT specialists, web developers and designers. Usability and heuristic testing with primary care professionals has been completed, and the CKD Clinical Pathway has been available online since November 4, 2014 (www.CKDpathway.ca). The content in the CKD Clinical Pathway is evidence based and uses international and national guidelines, including the KDIGO CKD guidelines,11 KDIGO Lipid guidelines,18 C-CHANGE,19 Canadian Diabetes Association (CDA) guidelines,20 Canadian Cardiovascular Society Lipid and Antiplatelet guidelines21,22 and Canadian Hypertension Education Program guidelines.23 This ensures that the recommendations are relevant and harmonized across Canada. Some of the content, such as the specialist referral form, is tailored to practice in Alberta. Users of the pathway should be aware that their local laboratory may report different reference ranges and units of measure than the laboratories in Alberta. Currently, laboratories in Alberta report estimated GFR using the CKD-EPI equation.24

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