Obsolete – Chronic Kidney Disease in Diabetes Mellitus – Decision Tool – Obsolete

New, Updated Decision Tool is at [link url="https://www.soapnote.org/kidney/ckd-tool/" memo="www.soapnote.org/kidney/ckd-tool/"]
Note - this decision tool is marked as obsoleted due to guidelines that were released by KDIGO in 2017.
Please go to [link url="https://www.soapnote.org/kidney/ckd-tool/" memo="www.soapnote.org/kidney/ckd-tool/"]


Chronic Kidney Disease in Diabetes Mellitus - Decision Tool - Obsolete
Summary:  This decision tool assists with management of patients with diabetic nephropathy (diabetes mellitus-related chronic kidney disease, stages III, IV, and V).  It is not intended to manage CKD patients on dialysis.
Note:  Detection of kidney disease should prompt a workup to determine the cause.  A recommended initial evaluation includes Complete Metabolic Panel, Urinalysis, Urine Albumin to Creatinine Ratio (UACR), Uric Acid, Phosphate, Complete Blood Count, ANA screen, Rheumatoid Factor, C3, C4, Hepatitis B sAg, Hepatitis C Ab, dilated retinal exam, and renal Ultrasound; if patient is over 40 years & UACR is positive then Serum and Urine Protein Electrophoreses, as well.

Lab and objective findings:
1. Estimated GFR --> [select name="Q1" value="GFR 30 - 59: CKD Stage III|GFR 15 - 29: CKD Stage IV|GFR 0 - 14: CKD Stage V"]  [comment memo="note:  Chronic Kidney Disease (CKD) is estimated Glomerular Filtration Rate (eGFR) < 60 ml/min or kidney damage for ≥ 3 months (e.g. urine sediment, abnormal imaging, or albuminuria (Urine Albumin to Creatinine Ratio (UACR) < 30mg/g = nl, 30-300 = micro, >300 = macro))"]
2. Gender --> [select name="Q2" value="male|female"]
3. Bicarbonate Level --> [select name="Q3" value="22 mmol/L and above (goal)|less than 22 mmol/L"]
4. [conditional field="Q2" condition="(Q2).is('male')"]Goal hemoglobin level for men is 13.5 mg/dL and above.[/conditional][conditional field="Q2" condition="(Q2).is('female')"]Goal hemoglobin level for women is 12 mg/dL and above.[/conditional]  Hemoglobin Level --> [select name="Q4" value="at or above goal|low"]
5. Blood Pressure --> [select name="Q5" value="below 130/80 (goal)|130/80 and above"]
6. Calcium Level --> [select name="Q6" value="above 10.2 mg/dL (very high)|9.6 to 10.2 mg/dL (high)|8.4 to 9.5 mg/dL (goal)|less than 8.4 mg/dL (low)"]
7. [conditional field="Q1" condition="(Q1).is('GFR 30 - 59: CKD Stage III')"]Goal Phosphate levels for CKD Stage III is 2.7 - 4.6 mg/dL. [/conditional][conditional field="Q1" condition="(Q1).is('GFR 15 - 29: CKD Stage IV')"]Goal Phosphate levels for CKD Stage IV is 2.7 - 4.6 mg/dL. [/conditional][conditional field="Q1" condition="(Q1).is('GFR 0 - 14: CKD Stage V')"]Goal Phosphate levels for CKD Stage V is 3.5 - 5.4 mg/dL. [/conditional]Phosphate Level --> [select name="Q7" value="at goal|high"]
8. [conditional field="Q1" condition="(Q1).is('GFR 30 - 59: CKD Stage III')"]iPTH levels for CKD Stage III:  Low is less than 35 pg/mL.  Goal is 35 - 70 pg/mL.  High is more than 70 pg/mL. [/conditional][conditional field="Q1" condition="(Q1).is('GFR 15 - 29: CKD Stage IV')"]iPTH levels for CKD Stage IV:  Low is less than 70 pg/mL.  Goal is 70 - 110 pg/mL.  High is more than 110 pg/mL. [/conditional][conditional field="Q1" condition="(Q1).is('GFR 0 - 14: CKD Stage V')"]iPTH levels for CKD Stage V:  Low is less than 150 pg/mL.  Goal is 150 - 300 pg/mL.  High is more than 300 pg/mL. [/conditional]Intact Parathyroid Hormone (iPTH) Level --> [select name="Q8" value="low|at goal|high"]
9. 25(OH)D (Vitamin D) Level --> [select name="Q9" value="30 mg/mL and above (goal)|less than 30 mg/mL"]
Recommendations:
[conditional field="Q1" condition="(Q1).is('GFR 30 - 59: CKD Stage III')"][textarea default="Follow up visit in 3 months.  Referral to registered dietician.  Lab interval for stage III CKD:  Creatinine and eGFR - Each visit; UACR - Every 3 or 6 months; Hb - Every 3 months; Fe, Transferrin Sat, Ferritin - Every 3 months; Ca, PO4, and iPTH - At least annually.  "][/conditional][conditional field="Q1" condition="(Q1).is('GFR 15 - 29: CKD Stage IV')"][textarea default="Follow up visit in at least 1 to 3 months. Referral to registered dietician.  Referral to nephrologist.  Lab interval for stage IV CKD:  Creatinine and eGFR - Each visit; UACR - Each visit; Hb - Every 3 months; Fe, Transferrin Sat, Ferritin - Every 3 months; Ca, PO4, and iPTH - Every 3 months.  "][/conditional][conditional field="Q1" condition="(Q1).is('GFR 0 - 14: CKD Stage V')"][textarea default="Follow up visit in at least 1 to 3 months.  Referral to registered dietician.  Referral to nephrologist.  Lab interval for stage V CKD (not on dialysis)Creatinine and eGFR - Each visit;UACR - Each visit;Hb - Every 3 months;Fe, Transferrin Sat, Ferritin - Every 3 months;Ca, PO4, and iPTH - Every 3 months.  "][/conditional]
[conditional field="Q3" condition="(Q3).is('22 mmol/L and above (goal)')"][textarea default="Acidosis is controlled.  Continue maintenance therapy if present, i.e.sodium bicarbonate 325-650 mg (1 to 2 tabs) TID to QID.  "][/conditional][conditional field="Q3" condition="(Q3).is('less than 22 mmol/L')"][textarea default="Acidosis is uncontrolled.  Sodium bicarbonate 325-650 mg (1 to 2 tabs) TID to QID.  "][/conditional]
[conditional field="Q4" condition="(Q4).is('at or above goal')"][textarea default="No anemia therapy indicated.  Continue ongoing iron supplementation as appropriate.  Monitor ferritin to avoid iron overload.  "][/conditional][conditional field="Q4" condition="(Q4).is('low')"][textarea default="Anemia is present.  Additional evaluation for other anemia causes: B12/folate; hemoccult/FIT/colonoscopy;Baseline Labs for anemia of CKD: Ferritin; iron studies (Fe, % Sat, TIBC); CBC with differential.  If ferritin/iron studies are low --> Start oral iron therapy, i.e. Ferrous Sulfate (FeSO4) 325mg QD to TID.  Docusate 100mg BID as needed to reduce constipation. Monitor ferritin to avoid iron overload.  If Hb < 9 with symptoms unresponsive to treatment--> IV iron/blood transfusion/erythropoiesis stimulating agents"][/conditional]
[conditional field="Q5" condition="(Q5).is('below 130/80 (goal)')"][textarea default="Hypertension is controlled.  Continue current therapy (ACE/ARB is first line)."]  [/conditional][conditional field="Q5" condition="(Q5).is('130/80 and above')"][textarea default="Hypertension is uncontrolled.  Increase ACE/ARB dosage; Add additional agent to lower blood pressure to goal < 130/80.  "][/conditional]
[conditional field="Q6|Q7|Q8|Q9" condition="(Q6).is('above 10.2 mg/dL (very high)')&&(Q7).is('at goal')&&(Q8).is('low')&&(Q9).is('30 mg/mL and above (goal)')"][textarea default="Severe hypercalcemia with low parathyroid hormone.  Further investigation is warranted.  Consider nephrology consultation.  Diet:  Limit dietary phosphate to 800-1000 mg/day.  Correct causes for hypercalcemia.  Increase iPTH and decrease calcium by holding calcitriol, vitamin D, and avoiding calcium-based phosphate binders."][/conditional][conditional field="Q6|Q7|Q8|Q9" condition="(Q6).is('above 10.2 mg/dL (very high)')&&(Q7).is('at goal')&&(Q8).is('low')&&(Q9).is('less than 30 mg/mL')"][textarea default="Severe hypercalcemia with low parathyroid hormone and low vitamin D.  Further investigation is warranted.  Consider nephrology consultation.  Diet:  Limit dietary phosphate to 800-1000 mg/day.  Correct causes for hypercalcemia.  Increase iPTH and decrease calcium by holding calcitriol, vitamin D, and avoiding calcium-based phosphate binders.  "][/conditional][conditional field="Q6|Q7|Q8|Q9" condition="(Q6).is('above 10.2 mg/dL (very high)')&&(Q7).is('at goal')&&(Q8).is('at goal')&&(Q9).is('30 mg/mL and above (goal)')"][textarea default="Severe hypercalcemia.  Further investigation is warranted.  Consider nephrology consultation.  Diet:  Limit dietary phosphate to 800-1000 mg/day.  Correct causes for hypercalcemia.  Decrease calcium by holding calcitriol, vitamin D, and avoiding calcium-based phosphate binders.  "][/conditional][conditional field="Q6|Q7|Q8|Q9" condition="(Q6).is('above 10.2 mg/dL (very high)')&&(Q7).is('at goal')&&(Q8).is('at goal')&&(Q9).is('less than 30 mg/mL')"][textarea default="Severe hypercalcemia with low vitamin D.  Further investigation is warranted.  Consider nephrology consultation.  Diet:  Limit dietary phosphate to 800-1000 mg/day.  Correct causes for hypercalcemia.  Decrease calcium by holding calcitriol, vitamin D, and avoiding calcium-based phosphate binders.  "][/conditional][conditional field="Q6|Q7|Q8|Q9" condition="(Q6).is('above 10.2 mg/dL (very high)')&&(Q7).is('at goal')&&(Q8).is('high')&&(Q9).is('30 mg/mL and above (goal)')"][textarea default="Severe hypercalcemia with elevated parathyroid hormone.  Further investigation is warranted.  Consider nephrology consultation.  Diet:  Limit dietary phosphate to 800-1000 mg/day.  Correct causes for hypercalcemia.  Decrease calcium by holding calcitriol, vitamin D, and avoiding calcium-based phosphate binders.  Cinacalcet 30-180 mg daily may be used to decrease calcium, phosphate, and PTH.  "][/conditional][conditional field="Q6|Q7|Q8|Q9" condition="(Q6).is('above 10.2 mg/dL (very high)')&&(Q7).is('at goal')&&(Q8).is('high')&&(Q9).is('less than 30 mg/mL')"][textarea default="Severe hypercalcemia with elevated parathyroid hormone and low vitamin D.  Further investigation is warranted.  Consider nephrology consultation.  Diet:  Limit dietary phosphate to 800-1000 mg/day.  Correct causes for hypercalcemia.  Decrease calcium by holding calcitriol, vitamin D, and avoiding calcium-based phosphate binders.  Cinacalcet 30-180 mg daily may be used to decrease calcium, phosphate, and PTH.  "][/conditional][conditional field="Q6|Q7|Q8|Q9" condition="(Q6).is('above 10.2 mg/dL (very high)')&&(Q7).is('high')&&(Q8).is('low')&&(Q9).is('30 mg/mL and above (goal)')"][textarea default="Severe hypercalcemia with hyperphosphatemia and low parathyroid hormone.  Further investigation is warranted.  Consider nephrology consultation.  Diet:  Limit dietary phosphate to 800-1000 mg/day (consult/reconsult registered dietician).  Correct causes for hypercalcemia.  Increase iPTH and decrease calcium by holding calcitriol, vitamin D, and avoiding calcium-based phosphate binders.  Sevelamer (Renagel) 800-1600 mg TID may be used to decrease phosphate.  Cinacalcet 30-180 mg daily may be used to decrease calcium, phosphate, and PTH.  Lanthanum 1500-3750 mg/day with meals to decrease phosphate and calcium.  Aluminum 600-1200 mg TID between meals & HS.  Can be used for up to 30 days to decrease phosphate if it is above 7 mg/dL.  "][/conditional][conditional field="Q6|Q7|Q8|Q9" condition="(Q6).is('above 10.2 mg/dL (very high)')&&(Q7).is('high')&&(Q8).is('low')&&(Q9).is('less than 30 mg/mL')"][textarea default="Severe hypercalcemia with hyperphosphatemia and low parathyroid hormone and low vitamin D.  Further investigation is warranted.  Consider nephrology consultation.  Diet:  Limit dietary phosphate to 800-1000 mg/day (consult/reconsult registered dietician).  Correct causes for hypercalcemia.  Increase iPTH and decrease calcium by holding calcitriol, vitamin D, and avoiding calcium-based phosphate binders.  Sevelamer (Renagel) 800-1600 mg TID may be used to decrease phosphate.  Cinacalcet 30-180 mg daily may be used to decrease calcium, phosphate, and PTH.  Lanthanum 1500-3750 mg/day with meals to decrease phosphate and calcium.  Aluminum 600-1200 mg TID between meals & HS.  Can be used for up to 30 days to decrease phosphate if it is above 7 mg/dL.  "][/conditional][conditional field="Q6|Q7|Q8|Q9" condition="(Q6).is('above 10.2 mg/dL (very high)')&&(Q7).is('high')&&(Q8).is('at goal')&&(Q9).is('30 mg/mL and above (goal)')"][textarea default="Severe hypercalcemia with hyperphosphatemia.  Further investigation is warranted.  Consider nephrology consultation.  Diet:  Limit dietary phosphate to 800-1000 mg/day (consult/reconsult registered dietician).  Correct causes for hypercalcemia.  Decrease calcium by holding calcitriol, vitamin D, and avoiding calcium-based phosphate binders.  Sevelamer (Renagel) 800-1600 mg TID may be used to decrease phosphate.  Cinacalcet 30-180 mg daily may be used to decrease calcium, phosphate, and PTH.  Lanthanum 1500-3750 mg/day with meals to decrease phosphate and calcium.  Aluminum 600-1200 mg TID between meals & HS.  Can be used for up to 30 days to decrease phosphate if it is above 7 mg/dL.  "][/conditional][conditional field="Q6|Q7|Q8|Q9" condition="(Q6).is('above 10.2 mg/dL (very high)')&&(Q7).is('high')&&(Q8).is('at goal')&&(Q9).is('less than 30 mg/mL')"][textarea default="Severe hypercalcemia with hyperphosphatemia and low vitamin D.  Further investigation is warranted.  Consider nephrology consultation.  Diet:  Limit dietary phosphate to 800-1000 mg/day (consult/reconsult registered dietician).  Correct causes for hypercalcemia.  Decrease calcium by holding calcitriol, vitamin D, and avoiding calcium-based phosphate binders.  Sevelamer (Renagel) 800-1600 mg TID may be used to decrease phosphate.  Cinacalcet 30-180 mg daily may be used to decrease calcium, phosphate, and PTH.  Lanthanum 1500-3750 mg/day with meals to decrease phosphate and calcium.  Aluminum 600-1200 mg TID between meals & HS.  Can be used for up to 30 days to decrease phosphate if it is above 7 mg/dL.  "][/conditional][conditional field="Q6|Q7|Q8|Q9" condition="(Q6).is('above 10.2 mg/dL (very high)')&&(Q7).is('high')&&(Q8).is('high')&&(Q9).is('30 mg/mL and above (goal)')"][textarea default="Severe hypercalcemia with hyperphosphatemia and elevated parathyroid hormone.  Further investigation is warranted.  Consider nephrology consultation.  Diet:  Limit dietary phosphate to 800-1000 mg/day (consult/reconsult registered dietician).  Correct causes for hypercalcemia.  Decrease calcium by holding calcitriol, vitamin D, and avoiding calcium-based phosphate binders.  Sevelamer (Renagel) 800-1600 mg TID may be used to decrease phosphate.  Cinacalcet 30-180 mg daily may be used to decrease calcium, phosphate, and PTH.  Lanthanum 1500-3750 mg/day with meals to decrease phosphate and calcium.  Aluminum 600-1200 mg TID between meals & HS.  Can be used for up to 30 days to decrease phosphate if it is above 7 mg/dL.  "][/conditional][conditional field="Q6|Q7|Q8|Q9" condition="(Q6).is('above 10.2 mg/dL (very high)')&&(Q7).is('high')&&(Q8).is('high')&&(Q9).is('less than 30 mg/mL')"][textarea default="Severe hypercalcemia with hyperphosphatemia, elevated parathyroid hormone, and low vitamin D.  Further investigation is warranted.  Consider nephrology consultation.  Diet:  Limit dietary phosphate to 800-1000 mg/day (consult/reconsult registered dietician).  Correct causes for hypercalcemia.  Decrease calcium by holding calcitriol, vitamin D, and avoiding calcium-based phosphate binders.  Sevelamer (Renagel) 800-1600 mg TID may be used to decrease phosphate.  Cinacalcet 30-180 mg daily may be used to decrease calcium, phosphate, and PTH.  Lanthanum 1500-3750 mg/day with meals to decrease phosphate and calcium.  Aluminum 600-1200 mg TID between meals & HS.  Can be used for up to 30 days to decrease phosphate if it is above 7 mg/dL.  "][/conditional][conditional field="Q6|Q7|Q8|Q9" condition="(Q6).is('9.6 to 10.2 mg/dL (high)')&&(Q7).is('at goal')&&(Q8).is('low')&&(Q9).is('30 mg/mL and above (goal)')"][textarea default="Hypercalcemia with low parathyroid hormone.  Diet:  Limit dietary phosphate to 800-1000 mg/day.  Increase iPTH and decrease calcium by holding calcitriol, vitamin D, and calcium-based phosphate binders.  "][/conditional][conditional field="Q6|Q7|Q8|Q9" condition="(Q6).is('9.6 to 10.2 mg/dL (high)')&&(Q7).is('at goal')&&(Q8).is('low')&&(Q9).is('less than 30 mg/mL')"][textarea default="Hypercalcemia with low parathyroid hormone and low vitamin D.  Diet:  Limit dietary phosphate to 800-1000 mg/day.  Increase iPTH and decrease calcium by holding calcitriol, vitamin D, and calcium-based phosphate binders.  Although vitamin D is low, supplementing this vitamin could harmfully increase calcium level.  "][/conditional][conditional field="Q6|Q7|Q8|Q9" condition="(Q6).is('9.6 to 10.2 mg/dL (high)')&&(Q7).is('at goal')&&(Q8).is('at goal')&&(Q9).is('30 mg/mL and above (goal)')"][textarea default="Hypercalcemia.  Diet:  Limit dietary phosphate to 800-1000 mg/day.  Increase iPTH and decrease calcium by holding calcitriol, vitamin D, and calcium-based phosphate binders.  "][/conditional][conditional field="Q6|Q7|Q8|Q9" condition="(Q6).is('9.6 to 10.2 mg/dL (high)')&&(Q7).is('at goal')&&(Q8).is('at goal')&&(Q9).is('less than 30 mg/mL')"][textarea default="Hypercalcemia with low vitamin D.  Diet:  Limit dietary phosphate to 800-1000 mg/day.  Increase iPTH and decrease calcium by holding calcitriol, vitamin D, and calcium-based phosphate binders.  Although vitamin D is low, supplementing this vitamin could harmfully increase calcium level.  "][/conditional][conditional field="Q6|Q7|Q8|Q9" condition="(Q6).is('9.6 to 10.2 mg/dL (high)')&&(Q7).is('at goal')&&(Q8).is('high')&&(Q9).is('30 mg/mL and above (goal)')"][textarea default="Hypercalcemia with elevated parathyroid hormone.  Diet:  Limit dietary phosphate to 800-1000 mg/day.  Decrease calcium by holding calcitriol and calcium-based phosphate binders.  Cinacalcet 30-180 mg daily may be used to decrease calcium, phosphate, and PTH.  "][/conditional][conditional field="Q6|Q7|Q8|Q9" condition="(Q6).is('9.6 to 10.2 mg/dL (high)')&&(Q7).is('at goal')&&(Q8).is('high')&&(Q9).is('less than 30 mg/mL')"][textarea default="Hypercalcemia with elevated parathyroid hormone and low vitamin D.  Diet:  Limit dietary phosphate to 800-1000 mg/day.  Decrease calcium by holding calcitriol and calcium-based phosphate binders.  Although vitamin D is low, supplementing this vitamin could harmfully increase calcium level.  "][/conditional][conditional field="Q6|Q7|Q8|Q9" condition="(Q6).is('9.6 to 10.2 mg/dL (high)')&&(Q7).is('high')&&(Q8).is('low')&&(Q9).is('30 mg/mL and above (goal)')"][textarea default="Hypercalcemia and hyperphosphatemia with low parathyroid hormone.  Further investigation is warranted.  Consider nephrology consultation.  Diet:  Limit dietary phosphate to 800-1000 mg/day (consult/reconsult registered dietician).  Decrease calcium and increase iPTH by holding calcitriol, vitamin D, and avoiding calcium-based phosphate binders.  Sevelamer (Renagel) 800-1600 mg TID may be used to decrease phosphate.  Lanthanum 1500-3750 mg/day with meals to decrease phosphate and calcium.  Aluminum 600-1200 mg TID between meals & HS.  Can be used for up to 30 days to decrease phosphate if it is above 7 mg/dL.  "][/conditional][conditional field="Q6|Q7|Q8|Q9" condition="(Q6).is('9.6 to 10.2 mg/dL (high)')&&(Q7).is('high')&&(Q8).is('low')&&(Q9).is('less than 30 mg/mL')"][textarea default="Hypercalcemia and hyperphosphatemia with low parathyroid hormone and low vitamin D.  Further investigation is warranted.  Consider nephrology consultation.  Diet:  Limit dietary phosphate to 800-1000 mg/day (consult/reconsult registered dietician).  Decrease calcium and increase iPTH by holding calcitriol, vitamin D, and avoiding calcium-based phosphate binders.  Sevelamer (Renagel) 800-1600 mg TID may be used to decrease phosphate.  Lanthanum 1500-3750 mg/day with meals to decrease phosphate and calcium.  Aluminum 600-1200 mg TID between meals & HS.  Can be used for up to 30 days to decrease phosphate if it is above 7 mg/dL.  "][/conditional][conditional field="Q6|Q7|Q8|Q9" condition="(Q6).is('9.6 to 10.2 mg/dL (high)')&&(Q7).is('high')&&(Q8).is('at goal')&&(Q9).is('30 mg/mL and above (goal)')"][textarea default="Hypercalcemia and hyperphosphatemia.  Further investigation is warranted.  Consider nephrology consultation.  Diet:  Limit dietary phosphate to 800-1000 mg/day (consult/reconsult registered dietician).  Decrease calcium by holding calcitriol and calcium-based phosphate binders.  Sevelamer (Renagel) 800-1600 mg TID may be used to decrease phosphate.  Cinacalcet 30-180 mg daily may be used to decrease calcium, phosphate, and PTH.  Lanthanum 1500-3750 mg/day with meals to decrease phosphate and calcium.  Aluminum 600-1200 mg TID between meals & HS.  Can be used for up to 30 days to decrease phosphate if it is above 7 mg/dL.  "][/conditional][conditional field="Q6|Q7|Q8|Q9" condition="(Q6).is('9.6 to 10.2 mg/dL (high)')&&(Q7).is('high')&&(Q8).is('at goal')&&(Q9).is('less than 30 mg/mL')"][textarea default="Hypercalcemia and hyperphosphatemia with low vitamin D.  Further investigation is warranted.  Consider nephrology consultation.  Diet:  Limit dietary phosphate to 800-1000 mg/day (consult/reconsult registered dietician).  Decrease calcium by holding calcitriol and calcium-based phosphate binders.  Sevelamer (Renagel) 800-1600 mg TID may be used to decrease phosphate.  If necessary, cinacalcet 30-180 mg daily may be used to decrease calcium, phosphate, and PTH.  Lanthanum 1500-3750 mg/day with meals to decrease phosphate and calcium.  Aluminum 600-1200 mg TID between meals & HS.  Can be used for up to 30 days to decrease phosphate if it is above 7 mg/dL.Although vitamin D is low, supplementing this vitamin could harmfully increase calcium level.  "][/conditional][conditional field="Q6|Q7|Q8|Q9" condition="(Q6).is('9.6 to 10.2 mg/dL (high)')&&(Q7).is('high')&&(Q8).is('high')&&(Q9).is('30 mg/mL and above (goal)')"][textarea default="Hypercalcemia and hyperphosphatemia with elevated parathyroid hormone.  Further investigation is warranted.  Consider nephrology consultation.  Diet:  Limit dietary phosphate to 800-1000 mg/day (consult/reconsult registered dietician).  Decrease calcium by holding calcitriol and calcium-based phosphate binders.  Sevelamer (Renagel) 800-1600 mg TID may be used to decrease phosphate.  Cinacalcet 30-180 mg daily may be used to decrease calcium, phosphate, and PTH.  Lanthanum 1500-3750 mg/day with meals to decrease phosphate and calcium.  Aluminum 600-1200 mg TID between meals & HS.  Can be used for up to 30 days to decrease phosphate if it is above 7 mg/dL.  "][/conditional][conditional field="Q6|Q7|Q8|Q9" condition="(Q6).is('9.6 to 10.2 mg/dL (high)')&&(Q7).is('high')&&(Q8).is('high')&&(Q9).is('less than 30 mg/mL')"][textarea default="Hypercalcemia and hyperphosphatemia with elevated parathyroid hormone and low vitamin D.  Further investigation is warranted.  Consider nephrology consultation.  Diet:  Limit dietary phosphate to 800-1000 mg/day (consult/reconsult registered dietician).  Decrease calcium by holding calcitriol and calcium-based phosphate binders.  Sevelamer (Renagel) 800-1600 mg TID may be used to decrease phosphate.  Cinacalcet 30-180 mg daily may be used to decrease calcium, phosphate, and PTH.  Lanthanum 1500-3750 mg/day with meals to decrease phosphate and calcium.  Aluminum 600-1200 mg TID between meals & HS.  Can be used for up to 30 days to decrease phosphate if it is above 7 mg/dL.Although vitamin D is low, supplementing this vitamin could harmfully increase calcium level.  "][/conditional][conditional field="Q6|Q7|Q8|Q9" condition="(Q6).is('8.4 to 9.5 mg/dL (goal)')&&(Q7).is('at goal')&&(Q8).is('low')&&(Q9).is('30 mg/mL and above (goal)')"][textarea default="Low parathyroid hormone.  Diet:  Limit dietary phosphate to 800-1000 mg/day.  Increase iPTH by holding calcitriol, vitamin D, and calcium-based phosphate binders.  "][/conditional][conditional field="Q6|Q7|Q8|Q9" condition="(Q6).is('8.4 to 9.5 mg/dL (goal)')&&(Q7).is('at goal')&&(Q8).is('low')&&(Q9).is('less than 30 mg/mL')"][textarea default="Low parathyroid hormone and low vitain D.  Diet:  Limit dietary phosphate to 800-1000 mg/day.  Increase iPTH by holding calcitriol, vitamin D, and calcium-based phosphate binders.  "][/conditional][conditional field="Q6|Q7|Q8|Q9" condition="(Q6).is('8.4 to 9.5 mg/dL (goal)')&&(Q7).is('at goal')&&(Q8).is('at goal')&&(Q9).is('30 mg/mL and above (goal)')"][textarea default="Phosphate, calcium, iPTH, and vitamin D are all at goal.  Diet:  Limit dietary phosphate to 800-1000 mg/day.  Continue current medications.  "][/conditional][conditional field="Q6|Q7|Q8|Q9" condition="(Q6).is('8.4 to 9.5 mg/dL (goal)')&&(Q7).is('at goal')&&(Q8).is('at goal')&&(Q9).is('less than 30 mg/mL')"][textarea default="Low vitamin D.  Diet:  Limit dietary phosphate to 800-1000 mg/day.  Increase vitamin D with ergocalciferol 1.25-5 mg daily.  "][/conditional][conditional field="Q6|Q7|Q8|Q9" condition="(Q6).is('8.4 to 9.5 mg/dL (goal)')&&(Q7).is('at goal')&&(Q8).is('high')&&(Q9).is('30 mg/mL and above (goal)')"][textarea default="Elevated parathyroid hormone.  Diet:  Limit dietary phosphate to 800-1000 mg/day.  Reduce iPTH with calcitriol 0.25-1 mcg daily or 0.5-3 mcg TIW.  "][/conditional][conditional field="Q6|Q7|Q8|Q9" condition="(Q6).is('8.4 to 9.5 mg/dL (goal)')&&(Q7).is('at goal')&&(Q8).is('high')&&(Q9).is('less than 30 mg/mL')"][textarea default="Elevated parathyroid hormone and low vitamin D.  Diet:  Limit dietary phosphate to 800-1000 mg/day.  Reduce iPTH and increase vitamin D with ergocalciferol 1.25-5 mg daily.  "][/conditional][conditional field="Q6|Q7|Q8|Q9" condition="(Q6).is('8.4 to 9.5 mg/dL (goal)')&&(Q7).is('high')&&(Q8).is('low')&&(Q9).is('30 mg/mL and above (goal)')"][textarea default="Hyperphosphatemia with low parathyroid hormone.  Further investigation is warranted.  Consider nephrology consultation.  Diet:  Limit dietary phosphate to 800-1000 mg/day (consult/reconsult registered dietician).  Increase iPTH by holding calcitriol, vitamin D, and calcium-based phosphate binders.  Sevelamer (Renagel) 800-1600 mg TID may be used to decrease phosphate.  Aluminum 600-1200 mg TID between meals & HS.  Can be used for up to 30 days to decrease phosphate if it is above 7 mg/dL.  "][/conditional][conditional field="Q6|Q7|Q8|Q9" condition="(Q6).is('8.4 to 9.5 mg/dL (goal)')&&(Q7).is('high')&&(Q8).is('low')&&(Q9).is('less than 30 mg/mL')"][textarea default="Hyperphosphatemia with low parathyroid hormone and low vitamin D.  Further investigation is warranted.  Consider nephrology consultation.  Diet:  Limit dietary phosphate to 800-1000 mg/day (consult/reconsult registered dietician).  Increase iPTH by holding calcitriol, vitamin D, and calcium-based phosphate binders.  Sevelamer (Renagel) 800-1600 mg TID may be used to decrease phosphate.  Aluminum 600-1200 mg TID between meals & HS.  Can be used for up to 30 days to decrease phosphate if it is above 7 mg/dL.  "][/conditional][conditional field="Q6|Q7|Q8|Q9" condition="(Q6).is('8.4 to 9.5 mg/dL (goal)')&&(Q7).is('high')&&(Q8).is('at goal')&&(Q9).is('30 mg/mL and above (goal)')"][textarea default="Hyperphosphatemia.  Diet:  Limit dietary phosphate to 800-1000 mg/day (consult/reconsult registered dietician).  CaCO3 (Oyst-Cal or TUMS) 500-2000 mg with meals to decrease phosphate and increase calcium. Ca Acetate 1334-2868 mg with meals to decrease phosphate (when it's above 5 mg/dL) and increase calcium.  Sevelamer (Renagel) 800-1600 mg TID may be used to decrease phosphate.  "][/conditional][conditional field="Q6|Q7|Q8|Q9" condition="(Q6).is('8.4 to 9.5 mg/dL (goal)')&&(Q7).is('high')&&(Q8).is('at goal')&&(Q9).is('less than 30 mg/mL')"][textarea default="Hyperphosphatemia with low vitamin D.  Diet:  Limit dietary phosphate to 800-1000 mg/day (consult/reconsult registered dietician).  CaCO3 (Oyst-Cal or TUMS) 500-2000 mg with meals to decrease phosphate and increase calcium. Ca Acetate 1334-2868 mg with meals to decrease phosphate (when it's above 5 mg/dL) and increase calcium.  Sevelamer (Renagel) 800-1600 mg TID may be used to decrease phosphate.  Aluminum 600-1200 mg TID between meals & HS.  Can be used for up to 30 days to decrease phosphate if it is above 7 mg/dL.Increase vitamin D with ergocalciferol 1.25-5 mg daily.  "][/conditional][conditional field="Q6|Q7|Q8|Q9" condition="(Q6).is('8.4 to 9.5 mg/dL (goal)')&&(Q7).is('high')&&(Q8).is('high')&&(Q9).is('30 mg/mL and above (goal)')"][textarea default="Hyperphosphatemia with elevated parathyroid hormone.  Diet:  Limit dietary phosphate to 800-1000 mg/day (consult/reconsult registered dietician).  CaCO3 (Oyst-Cal or TUMS) 500-2000 mg with meals to decrease phosphate and increase calcium. Ca Acetate 1334-2868 mg with meals to decrease phosphate (when it's above 5 mg/dL) and increase calcium.  Sevelamer (Renagel) 800-1600 mg TID may be used to decrease phosphate.  Aluminum 600-1200 mg TID between meals & HS.  Can be used for up to 30 days to decrease phosphate if it is above 7 mg/dL.Reduce iPTH with calcitriol 0.25-1 mcg daily or 0.5-3 mcg TIW.  "][/conditional][conditional field="Q6|Q7|Q8|Q9" condition="(Q6).is('8.4 to 9.5 mg/dL (goal)')&&(Q7).is('high')&&(Q8).is('high')&&(Q9).is('less than 30 mg/mL')"][textarea default="Hyperphosphatemia with elevated parathyroid hormone and low vitamin D.  Diet:  Limit dietary phosphate to 800-1000 mg/day (consult/reconsult registered dietician).  CaCO3 (Oyst-Cal or TUMS) 500-2000 mg with meals to decrease phosphate and increase calcium. Ca Acetate 1334-2868 mg with meals to decrease phosphate (when it's above 5 mg/dL) and increase calcium.  Sevelamer (Renagel) 800-1600 mg TID may be used to decrease phosphate.  Aluminum 600-1200 mg TID between meals & HS.  Can be used for up to 30 days to decrease phosphate if it is above 7 mg/dL.Reduce iPTH and increase vitamin D with ergocalciferol 1.25-5 mg daily.  "][/conditional][conditional field="Q6|Q7|Q8|Q9" condition="(Q6).is('less than 8.4 mg/dL (low)')&&(Q7).is('at goal')&&(Q8).is('low')&&(Q9).is('30 mg/mL and above (goal)')"][textarea default="Hypocalcemia with low parathyroid hormone.  Further investigation is warranted.  Consider nephrology consultation.  Diet:  Limit dietary phosphate to 800-1000 mg/day.  Increase iPTH by holding calcitriol, vitamin D, and/or calcium-based phosphate binders.  "][/conditional][conditional field="Q6|Q7|Q8|Q9" condition="(Q6).is('less than 8.4 mg/dL (low)')&&(Q7).is('at goal')&&(Q8).is('low')&&(Q9).is('less than 30 mg/mL')"][textarea default="Hypocalcemia with low parathyroid hormone and low vitamin D.  Further investigation is warranted.  Consider nephrology consultation.  Diet:  Limit dietary phosphate to 800-1000 mg/day.  Increase iPTH by holding calcitriol, vitamin D, and/or calcium-based phosphate binders.  "][/conditional][conditional field="Q6|Q7|Q8|Q9" condition="(Q6).is('less than 8.4 mg/dL (low)')&&(Q7).is('at goal')&&(Q8).is('at goal')&&(Q9).is('30 mg/mL and above (goal)')"][textarea default="Hypocalcemia.  Diet:  Limit dietary phosphate to 800-1000 mg/day.  Increase calcium by starting/increasing calcium supplementation.  CaCO3 (Oyst-Cal or TUMS) 500-2000 mg with meals to decrease phosphate and increase calcium. Ca Acetate 1334-2868 mg with meals to decrease phosphate (when it's above 5 mg/dL) and increase calcium.  "][/conditional][conditional field="Q6|Q7|Q8|Q9" condition="(Q6).is('less than 8.4 mg/dL (low)')&&(Q7).is('at goal')&&(Q8).is('at goal')&&(Q9).is('less than 30 mg/mL')"][textarea default="Hypocalcemia with low vitamin D.  Diet:  Limit dietary phosphate to 800-1000 mg/day.  Increase calcium and vitamin D by starting/increasing calcium supplementation and/or vitamin D.  CaCO3 (Oyst-Cal or TUMS) 500-2000 mg with meals to decrease phosphate and increase calcium. Ca Acetate 1334-2868 mg with meals to decrease phosphate (when it's above 5 mg/dL) and increase calcium.  Increase vitamin D with ergocalciferol 1.25-5 mg daily.  "][/conditional][conditional field="Q6|Q7|Q8|Q9" condition="(Q6).is('less than 8.4 mg/dL (low)')&&(Q7).is('at goal')&&(Q8).is('high')&&(Q9).is('30 mg/mL and above (goal)')"][textarea default="Hypocalcemia with elevated parathyroid hormone.  Diet:  Limit dietary phosphate to 800-1000 mg/day.  Reduce iPTH and increase calcium with calcitriol 0.25-1 mcg daily or 0.5-3 mcg TIW.  "][/conditional][conditional field="Q6|Q7|Q8|Q9" condition="(Q6).is('less than 8.4 mg/dL (low)')&&(Q7).is('at goal')&&(Q8).is('high')&&(Q9).is('less than 30 mg/mL')"][textarea default="Hypocalcemia with elevated parathyroid hormone and low vitamin D.  Diet:  Limit dietary phosphate to 800-1000 mg/day.  Reduce iPTH, increase vitamin D, and increase calcium with ergocalciferol 1.25-5 mg daily.  "][/conditional][conditional field="Q6|Q7|Q8|Q9" condition="(Q6).is('less than 8.4 mg/dL (low)')&&(Q7).is('high')&&(Q8).is('low')&&(Q9).is('30 mg/mL and above (goal)')"][textarea default="Hypocalcemia and hyperphosphatemia with low parathyroid hormone.  Further investigation is warranted.  Consider nephrology consultation.  Limit dietary phosphate to 800-1000 mg/day (consult/reconsult registered dietician).  Increase iPTH by holding calcitriol, vitamin D, and calcium-based phosphate binders.  Sevelamer (Renagel) 800-1600 mg TID may be used to decrease phosphate.  Aluminum 600-1200 mg TID between meals & HS.  Can be used for up to 30 days to decrease phosphate if it is above 7 mg/dL.  "][/conditional][conditional field="Q6|Q7|Q8|Q9" condition="(Q6).is('less than 8.4 mg/dL (low)')&&(Q7).is('high')&&(Q8).is('low')&&(Q9).is('less than 30 mg/mL')"][textarea default="Hypocalcemia and hyperphosphatemia with low parathyroid hormone and low vitamin D.  Further investigation is warranted.  Consider nephrology consultation.  Limit dietary phosphate to 800-1000 mg/day (consult/reconsult registered dietician).  Increase iPTH by holding calcitriol, vitamin D, and calcium-based phosphate binders.  Sevelamer (Renagel) 800-1600 mg TID may be used to decrease phosphate.  Aluminum 600-1200 mg TID between meals & HS.  Can be used for up to 30 days to decrease phosphate if it is above 7 mg/dL.  "][/conditional][conditional field="Q6|Q7|Q8|Q9" condition="(Q6).is('less than 8.4 mg/dL (low)')&&(Q7).is('high')&&(Q8).is('at goal')&&(Q9).is('30 mg/mL and above (goal)')"][textarea default="Hypocalcemia and hyperphosphatemia.  Limit dietary phosphate to 800-1000 mg/day (consult/reconsult registered dietician).  CaCO3 (Oyst-Cal or TUMS) 500-2000 mg with meals to decrease phosphate and increase calcium. Ca Acetate 1334-2868 mg with meals to decrease phosphate (when it's above 5 mg/dL) and increase calcium.  "][/conditional][conditional field="Q6|Q7|Q8|Q9" condition="(Q6).is('less than 8.4 mg/dL (low)')&&(Q7).is('high')&&(Q8).is('at goal')&&(Q9).is('less than 30 mg/mL')"][textarea default="Hypocalcemia and hyperphosphatemia with low Vitamin D.  Diet:  Limit dietary phosphate to 800-1000 mg/day (consult/reconsult registered dietician).  CaCO3 (Oyst-Cal or TUMS) 500-2000 mg with meals to decrease phosphate and increase calcium. Ca Acetate 1334-2868 mg with meals to decrease phosphate (when it's above 5 mg/dL) and increase calcium.  Reduce iPTH, increase vitamin D, and increase calcium with ergocalciferol 1.25-5 mg daily.  "][/conditional][conditional field="Q6|Q7|Q8|Q9" condition="(Q6).is('less than 8.4 mg/dL (low)')&&(Q7).is('high')&&(Q8).is('high')&&(Q9).is('30 mg/mL and above (goal)')"][textarea default="Hypocalcemia and hyperphosphatemia with elevated parathyroid hormone.  Limit dietary phosphate to 800-1000 mg/day (consult/reconsult registered dietician).  CaCO3 (Oyst-Cal or TUMS) 500-2000 mg with meals to decrease phosphate and increase calcium. Ca Acetate 1334-2868 mg with meals to decrease phosphate (when it's above 5 mg/dL) and increase calcium.  Reduce iPTH and increase calcium with calcitriol 0.25-1 mcg daily or 0.5-3 mcg TIW.  "][/conditional][conditional field="Q6|Q7|Q8|Q9" condition="(Q6).is('less than 8.4 mg/dL (low)')&&(Q7).is('high')&&(Q8).is('high')&&(Q9).is('less than 30 mg/mL')"][textarea default="Hypocalcemia and hyperphosphatemia with elevated parathyroid hormone and low vitamin D.  Limit dietary phosphate to 800-1000 mg/day (consult/reconsult registered dietician).  CaCO3 (Oyst-Cal or TUMS) 500-2000 mg with meals to decrease phosphate and increase calcium. Ca Acetate 1334-2868 mg with meals to decrease phosphate (when it's above 5 mg/dL) and increase calcium.  Reduce iPTH, increase vitamin D, and increase calcium with ergocalciferol 1.25-5 mg daily.  "][/conditional]
[checkbox memo="display/hide references" name="footnotes" value=""][conditional field="footnotes" condition="(footnotes).is('')"]
references:  
[link memo="#1" url="http://www.ihs.gov/MedicalPrograms/Diabetes/HomeDocs/Tools/Algorithms/DM_algorithm_CKD_508c.pdf"] Indian Health Service Guideline (2010) Type 2 Diabetes - Chronic Kidney Disease 
[link memo="#2" url="http://www.fpnotebook.com/renal/Rheum/RnlOstdystrphy.htm"] FP Notebook Renal Osteodystrophy page [/conditional]
New, Updated Decision Tool is at www.soapnote.org/kidney/ckd-tool/
Note - this decision tool is marked as obsoleted due to guidelines that were released by KDIGO in 2017.
Please go to www.soapnote.org/kidney/ckd-tool/


Chronic Kidney Disease in Diabetes Mellitus - Decision Tool - Obsolete
Summary: This decision tool assists with management of patients with diabetic nephropathy (diabetes mellitus-related chronic kidney disease, stages III, IV, and V). It is not intended to manage CKD patients on dialysis.
Note: Detection of kidney disease should prompt a workup to determine the cause. A recommended initial evaluation includes Complete Metabolic Panel, Urinalysis, Urine Albumin to Creatinine Ratio (UACR), Uric Acid, Phosphate, Complete Blood Count, ANA screen, Rheumatoid Factor, C3, C4, Hepatitis B sAg, Hepatitis C Ab, dilated retinal exam, and renal Ultrasound; if patient is over 40 years & UACR is positive then Serum and Urine Protein Electrophoreses, as well.

Lab and objective findings:
1. Estimated GFR --> note: Chronic Kidney Disease (CKD) is estimated Glomerular Filtration Rate (eGFR) < 60 ml/min or kidney damage for ≥ 3 months (e.g. urine sediment, abnormal imaging, or albuminuria (Urine Albumin to Creatinine Ratio (UACR) < 30mg/g = nl, 30-300 = micro, >300 = macro))
2. Gender -->
3. Bicarbonate Level -->
4. Hemoglobin Level -->
5. Blood Pressure -->
6. Calcium Level -->
7. Phosphate Level -->
8. Intact Parathyroid Hormone (iPTH) Level -->
9. 25(OH)D (Vitamin D) Level -->
Recommendations:





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Sandbox Metrics: Structured Data Index 0.15, 138 form elements, 184 boilerplate words, 57 text areas, 1 checkboxes, 9 drop downs, 4 links, 1 comments, 66 conditionals, 67 total clicks
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