From the Research
For a patient with Chronic Kidney Disease (CKD) stage 3a, the chart should document the estimated glomerular filtration rate (eGFR) of 45-59 mL/min/1.73m², which defines this stage, as well as essential laboratory results and management plans to slow disease progression and reduce morbidity and mortality, as supported by the most recent study 1.
Essential Documentation
The following information should be included in the chart:
- Current serum creatinine, blood urea nitrogen (BUN), electrolytes (particularly potassium, calcium, and phosphorus), hemoglobin, and urinalysis results showing protein levels
- Blood pressure readings, with a target of <130/80 mmHg, as hypertension management is crucial in CKD patients 2
- Medication documentation, including:
- Nephrotoxic medications to avoid (NSAIDs, certain antibiotics)
- Current antihypertensives (ACE inhibitors or ARBs are often preferred)
- Phosphate binders or vitamin D supplements if prescribed
- Comorbidities that affect kidney function, such as:
- Diabetes (with HbA1c values)
- Hypertension
- Cardiovascular disease
Additional Considerations
The chart should also include:
- Dietary recommendations (sodium, protein, potassium restrictions)
- Vaccination status (particularly pneumococcal and influenza)
- Frequency of monitoring (typically every 6 months for CKD 3a)
- Documentation of patient education regarding disease progression, medication adherence, and lifestyle modifications This thorough documentation is essential for tracking disease progression and guiding appropriate interventions to slow CKD advancement, as highlighted in the recent study 1, which demonstrated that a recorded CKD diagnosis is associated with significant improvements in CKD management and monitoring practices and attenuated eGFR decline.