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2011 CPG Management of Chronic Kidney Disease in Adults

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Management of chronic kidney disease in adults.
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Management of Chronic Kidney Disease in Adults
July 2010 MOH/P/PAK/205.10 (GU)






Management of Chronic Kidney Disease in Adults
STATEMENT OF INTENT
These clinical practice guidelines (CPG) are meant to be guides for
clinical practice, based on the best available evidence at the time of
development. Adherence to these guidelines may not necessarily
guarantee the best outcome in every case. Every healthcare provider is
responsible for the management of his/her unique patient based on the
clinical picture presented by the patient and the management options
available locally.
These guidelines are issued in 2011 and will be reviewed in 2015 or
sooner if new evidence becomes available.
CPG Secretariat
Health Technology Assessment Section
Medical Development Division
Ministry of Health Malaysia
4th Floor, Block E1, Parcel E
62590 Putrajaya
Electronic version available on the following website:
http://www.moh.gov.my
http://www.acadmed.org.my

Management of Chronic Kidney Disease in Adults
TABLE OF CONTENTS
No. TITLE
Page

LEVELS OF EVIDENCE AND GRADES OF
i

RECOMMENDATION


GUIDELINES DEVELOPMENT AND OBJECTIVES
ii

DEVELOPMENT GROUP
v

REVIEW COMMITTEE
vi

EXTERNAL REVIEWERS
vii

ALGORITHM 1: SCREENING AND INVESTIGATIONS
viii

FOR CKD IN PATIENTS WITH DIABETES

ALGORITHM 2: SCREENING AND INVESTIGATIONS
ix

FOR CKD IN PATIENTS WITHOUT DIABETES


ALGORITHM 3: TREATMENT FOR CHRONIC
x

KIDNEY DISEASE



1.
INTRODUCTION
1
2.
SCREENING & INVESTIGATIONS
2

2.1 Who Should Be Screened?
2

2.2 Methods for Screening
4

2.3 Cost-effectiveness of Screening
6

2.4 Renal Function
7

2.5 Renal Tract Ultrasound
9


3.
CLASSIFICATION
10
4.
TREATMENT
12

4.1 Treatment of Hypertension and Proteinuria
12

4.2 Optimal Blood Pressure Range
16

4.3 Optimal Proteinuria Reduction
19

4.4 Monitoring of Renal Function
20

4.5 Optimal Glycaemic Control
21

4.6 Coronary Artery Disease
21

4.7 Dietary Intervention
25

4.8 Lifestyle Modification
27

4.9 Special Precautions
27


5.
PREGNANCY
29
6.
REFERRAL
31


7.
IMPLEMENTING THE GUIDELINES
33

Management of Chronic Kidney Disease in Adults
TABLE OF CONTENTS
No. TITLE
Page

REFERENCES
36



Appendix 1 Search Terms
45

Appendix 2 Clinical Questions
46

Appendix 3 Dosage Recommendation in CKD for
47


Commonly Prescribed Oral Medications
Appendix 4 Diet Plan and Menu Suggestion
55

List of Abbreviations
57

Acknowledgement
58

Disclosure Statement
58

Sources of Funding
58

Management of Chronic Kidney Disease in Adults
LEVELS OF EVIDENCE
Level Study design
I
Evidence from at least one properly randomised controlled trial
II -1
Evidence obtained from well-designed controlled trials without
randomisation
II-2
Evidence obtained from well-designed cohort or case-control
analytic studies, preferably from more than one centre or
group
II-3
Evidence from multiple time series with or without intervention.
Dramatic results in uncontrolled experiments (such as the
results of the introduction of penicillin treatment in the 1940s)
could also be regarded as this type of evidence
III
Opinions of respected authorities based on clinical experience;
descriptive studies and case reports; or reports of expert
committees
SOURCE: US / CANADIAN PREVENTIVE SERVICES TASK FORCE
GRADES OF RECOMMENDATION
A
At least one meta analysis, systematic review, or RCT, or
evidence rated as good and directly applicable to the target
population
B
Evidence from well conducted clinical trials, directly applicable
to the target population, and demonstrating overall consistency
of results; or evidence extrapolated from meta analysis,
systematic review, or RCT
C
Evidence from expert committee reports, or opinions and /or
clinical experiences of respected authorities; indicates absence
of directly applicable clinical studies of good quality
SOURCE: MODIFIED FROM THE SCOTTISH INTERCOLLEGIATE GUIDELINES NETWORK
(SIGN)
Note: The grades of recommendation relates to the strength of the
evidence on which the recommendation is based. It does not refl ect the
clinical importance of the recommendation.
i

Management of Chronic Kidney Disease in Adults
GUIDELINES DEVELOPMENT AND OBJECTIVES
GUIDELINES DEVELOPMENT
The Development Group (DG) for this Clinical Practice Guidelines
(CPG) was from the Ministry of Health (MOH), Ministry of Higher
Education and private sector. They consisted of nephrologists, a
general physician, an endocrinologist, a cardiologist, an obstetrician &
gynaecologist, family medicine specialists, a public health physician,
a general practitioner, pharmacists, a dietitian and a nursing matron.
There was active involvement of a multidisciplinary Review Committee
(RC) during the process of development of these guidelines.
Literature search was carried out at the following electronic databases:
Guidelines International Network (G-I-N); Pubmed; Medline, Cochrane
Database of Systemic Reviews (CDSR), Journal full text via OVID
search engine; International Health Technology Assessment websites
(refer to Appendix 1 for Search Terms). In addition, the reference lists of
all retrieved literatures and guidelines were searched to identify relevant
studies. Experts in the field were also contacted to identify further
studies. All searches were officially conducted between 10 September
2009 and 31 March 2010. Future CPG updates will consider evidence
published after this cut-off date. The details of the search strategy can
be obtained upon request from the CPG Secretariat.
Reference was also made to other guidelines on Chronic Kidney
Disease (CKD) such as Scottish Intercollegiate Guidelines Network
(SIGN) - Diagnosis and Management of Chronic Kidney Disease
(2008), National Institute of Clinical Excellence (NICE), London
- Chronic Kidney Disease (2008), Kidney Health Australia - Chronic
Kidney Disease Management in General Practice (2007), Royal
College of Physicians, London - Chronic Kidney Disease in Adults: UK
Guidelines for Identification, Management and Referral (2006), Ministry
of Health Malaysia - Diabetic Nephropathy (2004) and National Kidney
Foundation-KDOQI - Clinical Practice Guidelines for Chronic Kidney
Disease (2002). These CPGs were evaluated using the Appraisal of
Guidelines for Research and Evaluation (AGREE) prior to them being
used as references.
The clinical questions were developed under three sections with 13
clinical questions. Members of the DG were assigned individual questions
within these sections (refer to Appendix 2 for Clinical Questions). The
DG members met a total of 21 times throughout the development of
these guidelines. All literatures retrieved were appraised by at least two
ii

Management of Chronic Kidney Disease in Adults
members, presented in evidence tables and further discussed during
DG meetings. All statements and recommendations formulated after
that were agreed upon by both the DG and RC. Where evidence was
insufficient, the recommendations were made by consensus of the DG
and RC. These CPG are based largely on the findings of systematic
reviews, meta-analyses and clinical trials, with local practices taken into
consideration.
The literature used in these guidelines were graded using the US/
Canadian Preventive Services Task Force Level of Evidence (2001),
while the grading of recommendation was modified from grades of
recommendation of the Scottish Intercollegiate Guidelines Network .
On completion, the draft guideline was sent for review by external
reviewers. It was posted on the MOH Malaysia official website for
feedback from any interested parties. It was also presented at the 27th
Malaysian Society of Nephrology Annual Congress held in May 2011 for
further review. The draft was finally presented to the Technical Advisory
Committee for CPG, and the HTA and CPG Council MOH Malaysia for
review and approval.
iii

Management of Chronic Kidney Disease in Adults
OBJECTIVES
The objectives of the CPG are to provide recommendations on the
following:
a) Prevention and reduction in risk of developing chronic kidney
disease (CKD)
b) Screening and early detection of CKD
c) Treatment of early CKD to prevent its progression to end-stage
renal disease
d) Reduction in risk of cardiovascular disease
CLINICAL QUESTIONS
Refer to Appendix 2
TARGET POPULATION
a. Inclusion criteria
Adults at risk of/with CKD
b. Exclusion criteria
Dialysis and renal transplant patients
The CPG will not address treatment for specific renal diseases or
complications of CKD such as anaemia, renal bone disease and
metabolic acidosis.
TARGET GROUP/USER
This document is intended to guide healthcare professionals and
relevant stakeholders in all levels of healthcare in the management of
CKD in adults including:
i. Doctors with emphasis on primary and secondary care
ii. Allied health professionals
iii. Trainees and medical students
iv. Policy makers
v. Patients and their advocates
vi. Professional societies
HEALTHCARE SETTINGS
Outpatient, inpatient and community settings
iv

Management of Chronic Kidney Disease in Adults
DEVELOPMENT GROUP
Chairperson
Dr. Ong Loke Meng
Consultant Nephrologist, Hospital Pulau Pinang
Members (alphabetical order)
Dr. Ang Hock Aun
Dr. Mohd. Faudzi Abdullah
Consultant Physician
Consultant Family Medicine Specialist
Hospital Seberang Jaya, Pulau Pinang
Klinik Kesihatan Padang Serai, Kedah
Dr. Anita Bhajan Manocha
Mdm. Ng Boon Yah
Consultant Nephrologist
Pharmacist
Hospital Seberang Jaya, Pulau Pinang
Hospital Pulau Pinang, Pulau Pinang
Dr. Ching Chen Hua
Ms. Ng Ru Shing
Consultant Nephrologist
Pharmacist
Hospital Sultanah Bahiyah, Kedah
Hospital Pulau Pinang, Pulau Pinang
Mdm. Eezsafryna Azalin Nordin
Dr. Ong Hean Teik
Dietitian
Consultant Cardiologist
Hospital Pulau Pinang, Pulau Pinang
HT Ong Heart Clinic, Pulau Pinang
Dr. Gnanasegaran Xavier
Dato' Dr. Rozina Mohamed Ghazalli
General Practitioner
Senior Consultant Nephrologist
Klinik Xavier, Pulau Pinang
Hospital Pulau Pinang, Pulau Pinang
Dr. Kow Fei Ping
Dr. Sunita Bavanandan
Family Medicine Specialist
Consultant Nephrologist
Klinik Kesihatan Bandar Baru Air Itam Hospital Kuala Lumpur, Kuala Lumpur
Pulau Pinang
Dr. Liew Yew Fong
Dr. Sharmini Diana Parampalam
Consultant Nephrologist
Consultant Obstetrician & Gynaecologist
Hospital Pulau Pinang, Pulau Pinang
Hospital Seberang Jaya, Pulau Pinang
Mdm. Lim Chooi Eng
Assoc. Prof. Dr. Yeow Toh Peng
Nursing Matron
Consultant Endocrinologist
Hospital Pulau Pinang, Pulau Pinang
Penang Medical College, Pulau Pinang
Dr. Mohd. Aminuddin Mohd. Yusof
Public Health Physician
Health Technology Assessment Section
Ministry of Health
v

Management of Chronic Kidney Disease in Adults
REVIEW COMMITTEE
The draft guidelines were reviewed by a panel of independent
expert referees, from both public and private sectors, and also
a patient advocate who were asked to comment primarily on the
comprehensiveness and accuracy in the interpretation of evidence
supporting the recommendations in the guidelines.
Chairperson
Datuk Dr. Ghazali Ahmad
Senior Consultant Nephrologist
Hospital Kuala Lumpur, Kuala Lumpur
Members (alphabetical order)
Prof. Dr. Abdul Rashid A Rahman
Dr. Philip N. Jeremiah
Consultant Physician
Consultant Nephrologist &
Cyberjaya University College of Medical
past President Malaysian Society of
Sciences, Selangor
Nephrology
Dr. Inderjeet Kaur Gill
Datin Dr. Rugayah Bakri
Senior Principal Assistant Director
Deputy Director
Medical Services Unit
Health Technology Assessment Section
Medical Services Development Section, MOH
Medical Development Section, MOH
Mdm. Lee Day Guat
Dr. Siti Sharina Anas
Manager
Pathologist
National Renal Registry
Hospital Putrajaya, Putrajaya

A. Prof. Dr. Kamaliah Mohd. Daud
Dato' Syed Sidi Idid Syed Abdullah Idid
Consultant Nephrologist
Member of National Kidney Foundation &
Universiti Sains Malaysia, Kelantan
Patient Advocate
Dato' Dr. K. Aris Chandran
Prof. Dr. Taufiq Teng Cheong Lieng
Senior Consultant General Physician
Consultant Family Medicine Specialist
Hospital Raja Permaisuri Bainun, Perak
International Medical University, Kuala Lumpur
Dr. Mohd. Fozi Kamarudin
A. Prof. Dr. Winnie Chee Siew Swee
Family Medicine Specialist
Consultant Dietitian
Klinik Kesihatan Kangar, Perlis
International Medical University, Kuala Lumpur
Prof. Dr. Nor Azmi Kamaruddin
Dato' Dr. Zaki Morad Mohamad Zaher
Consultant Endocrinologist,
Consultant Nephrologist &
Pusat Perubatan Universiti Kebangsaan
Chairman National Kidney Foundation
Malaysia, Kuala Lumpur
Mdm. Norkasihan Ibrahim
Pharmacist
Hospital Selayang, Selangor
vi

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