What are the appropriate admitting orders for patients with Chronic Kidney Disease (CKD) stage V?

Admitting Orders for CKD Stage V Patients

For patients with CKD stage V requiring hospital admission, immediately implement nephrology consultation, strict fluid and electrolyte monitoring, medication dose adjustments for renal clearance, and preparation for potential urgent dialysis initiation. 1

Immediate Consultations and Assessments

• Nephrology consultation is mandatory for all CKD stage V admissions, as specialist involvement improves outcomes, reduces costs, and facilitates timely dialysis preparation or transplantation planning 1, 2
• Assess for urgent dialysis indications including uremic symptoms, BUN >100 mg/dL with altered mental status, refractory volume overload, severe hyperkalemia, uremic encephalopathy, pericarditis, or severe metabolic acidosis (pH <7.2) 1
• Calculate creatinine clearance (CrCl) immediately upon admission to guide medication dosing adjustments 3

Fluid Management

• Restrict IV fluids carefully - if sepsis or acute illness requires resuscitation, use crystalloid at 20-30 mL/kg over first 3 hours, then reduce to maintenance rate of 1-1.5 mL/kg/hr with frequent reassessment 4
• Monitor for volume overload every 2-4 hours by assessing respiratory crackles, peripheral edema, jugular venous distension, and oxygenation status 4
• Use loop diuretics (not thiazides) for volume control if fluid overload develops 1
• Restrict dietary sodium to <2g per day 1
• Consider urgent hemodialysis if severe volume overload develops with respiratory compromise 4

Blood Pressure Management

• Target systolic blood pressure <120 mmHg when tolerated using standardized office measurement 1
• Continue ACE inhibitor or ARB unless contraindicated (creatinine rise >30% within 4 weeks of initiation, severe hyperkalemia) 1
• Check blood pressure with each dose if patient receives erythropoietin or analogue 3
• Add loop diuretics as second-line agents for blood pressure control 1

Electrolyte and Metabolic Monitoring

• Check serum potassium, creatinine, bicarbonate, calcium, and phosphorus on admission and daily initially 3, 1
• Monitor for metabolic acidosis (serum bicarbonate) regularly 3
• Manage hyperkalemia with dietary restriction and potassium binders rather than immediately discontinuing ACE inhibitor/ARB 1
• Monitor serum calcium and phosphorus every 3-6 months in stable patients 1
• Monitor PTH every 6-12 months 1
• Measure 25(OH)D levels and correct deficiency 1

Medication Adjustments

Dose Adjustments Required

• Adjust all renally cleared medications according to pharmacokinetic data for CrCl <15 mL/min/1.73 m² 3
• Reduce insulin requirements by 50% of total daily dose for type 2 diabetes, or 35-40% for type 1 diabetes 3
• For DPP-4 inhibitors: sitagliptin 25 mg daily, saxagliptin 2.5 mg daily, alogliptin 6.25 mg daily 3
• Use glipizide as preferred sulfonylurea with conservative initial dosing (2.5 mg daily) 3

Medications to Avoid

• Discontinue metformin immediately - contraindicated due to lactic acidosis risk 3
• Avoid glyburide - contraindicated in CKD stage V 3
• Avoid NSAIDs and COX-2 inhibitors - nephrotoxic 1, 2
• Avoid nephrotoxic contrast media unless absolutely necessary with adequate hydration 3
• Calculate contrast volume to CrCl ratio if cardiac catheterization required 3

Medications to Continue/Consider

• Continue SGLT2 inhibitor if already prescribed for type 2 diabetes, even with eGFR <20 mL/min/1.73 m² unless dialysis initiated 1
• Continue ACE inhibitor/ARB for proteinuria reduction unless contraindicated 1

Pain Management

• Use acetaminophen as first-line for mild pain (maximum 3000 mg/day) 5
• Fentanyl and buprenorphine (transdermal or IV) are the safest opioids for CKD stage V patients 5
• All other opioids require significant dose reduction and careful monitoring due to metabolite accumulation 5
• Prescribe laxatives prophylactically for opioid-induced constipation 5
• Consider non-pharmacological approaches including exercise and local heat for musculoskeletal pain 5
• Use gabapentin (starting 100-300 mg at night) or pregabalin (starting 50 mg three times daily) for neuropathic pain with appropriate dose adjustments 5

Anemia Management

• Perform complete blood count at least monthly after initial stabilization 1
• Assess and treat underlying causes of anemia 1
• Monitor blood pressure with each erythropoietin dose 3

Glycemic Monitoring (if diabetic)

• Do not use HbA1c for glycemic monitoring in CKD stage V on dialysis - unreliable due to altered red blood cell turnover 3
• Use point-of-care blood glucose monitoring or consider continuous glucose monitoring with Glucose Management Indicator (CGMI) 3
• Be aware that acetaminophen levels >8 mg/dL may cause falsely high glucose readings 3

Preparation for Renal Replacement Therapy

• Evaluate vascular access status - if no arteriovenous fistula present and hemodialysis likely, arrange vascular surgery consultation for AVF creation 1
• Assess candidacy for peritoneal dialysis or preemptive kidney transplantation 1
• Provide structured education about dialysis options to patient and family 1, 6

Common Pitfalls to Avoid

• Do not combine ACE inhibitor with ARB - increases hyperkalemia and acute kidney injury risk 1
• Avoid excessive fluid resuscitation which precipitates pulmonary edema more rapidly in CKD patients 4
• Do not delay nephrology consultation when considering dialysis initiation 4
• Avoid using thiazide diuretics - ineffective in CKD stage V 1
• Do not immediately discontinue ACE inhibitor/ARB for mild hyperkalemia - manage hyperkalemia first 1

Admission Laboratory Orders

• Complete metabolic panel (sodium, potassium, chloride, bicarbonate, BUN, creatinine, glucose, calcium, phosphorus)
• Complete blood count with differential
• Magnesium level
• Parathyroid hormone (PTH)
• 25-hydroxyvitamin D level
• Urinalysis if not anuric
• Electrocardiogram (assess for hyperkalemia changes)

Daily Monitoring Parameters

• Strict intake and output measurement
• Daily weights
• Blood pressure monitoring (at least twice daily, more frequently if on erythropoietin)
• Daily electrolytes (potassium, creatinine, bicarbonate) until stable
• Assess for signs of uremia (altered mental status, pericardial rub, asterixis)
• Monitor for volume status (lung exam, peripheral edema, jugular venous pressure)