What are the sample doctor's orders for a patient with Chronic Kidney Disease (CKD)?

Sample Doctor's Orders for Chronic Kidney Disease (CKD)

Based on the 2024 KDIGO guidelines, CKD management requires a structured multi-drug approach prioritizing SGLT2 inhibitors, RAS inhibitors, and cardiovascular risk reduction to reduce mortality and improve quality of life. 1

Initial Assessment Orders

• Complete metabolic panel including serum creatinine, eGFR, electrolytes (sodium, potassium, bicarbonate), calcium, phosphate 1
• Urine albumin-to-creatinine ratio (ACR) on spot urine sample 1
• Lipid panel (total cholesterol, LDL, HDL, triglycerides) 1
• HbA1c if diabetes suspected or known 1
• Complete blood count to assess for anemia 2
• Serum uric acid 1
• 25-hydroxyvitamin D level 2
• Parathyroid hormone (PTH) if eGFR <45 ml/min/1.73 m² 2
• 12-lead electrocardiogram 1

Pharmacological Orders

For CKD with Albuminuria (A2 or A3)

1. RAS Inhibitor (First-line for albuminuria) 1

• ACE inhibitor (e.g., lisinopril 10-40 mg daily OR enalapril 10-20 mg twice daily) OR
• ARB (e.g., losartan 50-100 mg daily OR valsartan 80-320 mg daily) if ACE inhibitor not tolerated
• Titrate to maximum approved tolerated dose to achieve proven trial benefits 1
• Recheck BP, serum creatinine, and potassium in 2-4 weeks after initiation or dose increase 1
• Continue therapy unless creatinine rises >30% within 4 weeks 1
• Do NOT discontinue when eGFR falls below 30 ml/min/1.73 m² unless symptomatic hypotension or uncontrolled hyperkalemia 1

For CKD with Type 2 Diabetes OR Significant Albuminuria

2. SGLT2 Inhibitor (Strongly recommended) 1

• If eGFR ≥20 ml/min/1.73 m² with diabetes: Start dapagliflozin 10 mg daily OR empagliflozin 10 mg daily 1
• If eGFR ≥20 ml/min/1.73 m² with ACR ≥200 mg/g: Start SGLT2i regardless of diabetes status 1
• If heart failure present: Start SGLT2i regardless of albuminuria level 1
• Continue even if eGFR falls below 20 ml/min/1.73 m² unless not tolerated or dialysis initiated 1
• Withhold during prolonged fasting, surgery, or critical illness (ketosis risk) 1
• Do NOT increase monitoring frequency after initiation; reversible eGFR decrease is expected and not an indication to stop 1

For Type 2 Diabetes with Persistent Albuminuria Despite RASi

3. Nonsteroidal Mineralocorticoid Receptor Antagonist 1

• If eGFR >25 ml/min/1.73 m², normal potassium, and ACR >30 mg/g despite maximum RASi: Start finerenone 10-20 mg daily 1
• Monitor serum potassium regularly after initiation to mitigate hyperkalemia risk 1
• Can be added to RASi + SGLT2i combination 1

For Type 2 Diabetes Not at Glycemic Target

4. GLP-1 Receptor Agonist 1, 3

• If HbA1c above target despite metformin and SGLT2i: Start long-acting GLP-1 RA with proven cardiovascular benefits (e.g., semaglutide 0.25 mg SC weekly, titrate to 1 mg weekly OR dulaglutide 0.75-1.5 mg SC weekly) 1, 3

Blood Pressure Management Orders

• Target systolic BP <120 mmHg when tolerated 3
• Home blood pressure monitoring log, measure twice daily 1
• If BP not controlled on RASi alone: Add calcium channel blocker (e.g., amlodipine 5-10 mg daily) 4
• Add thiazide or thiazide-like diuretic (e.g., chlorthalidone 12.5-25 mg daily) if eGFR ≥30 ml/min/1.73 m² 4
• Switch to loop diuretic (e.g., furosemide 20-80 mg daily) if eGFR <30 ml/min/1.73 m² 4

Cardiovascular Risk Reduction Orders

5. Statin Therapy (Strongly recommended) 1

• If age ≥50 years with eGFR <60 ml/min/1.73 m²: Start atorvastatin 40-80 mg daily OR rosuvastatin 20-40 mg daily 1
• If age ≥50 years with eGFR ≥60 ml/min/1.73 m²: Start moderate-intensity statin 1
• If age 18-49 years with diabetes, prior MI/stroke, or 10-year CV risk >10%: Start statin therapy 1
• Consider adding ezetimibe 10 mg daily to maximize LDL reduction 1

6. Antiplatelet Therapy (If indicated) 1

• If established ischemic cardiovascular disease: Aspirin 81 mg daily for secondary prevention 1
• If aspirin intolerance: Consider P2Y12 inhibitor (e.g., clopidogrel 75 mg daily) 1

Metabolic Complication Management Orders

7. For Metabolic Acidosis 1

• If serum bicarbonate <18 mmol/L: Start sodium bicarbonate 650 mg (1 tablet) three times daily, titrate to maintain bicarbonate 22-26 mmol/L 1

8. For Hyperkalemia 1

• If potassium 5.5-6.0 mEq/L on RASi: Start patiromer 8.4 g daily OR sodium zirconium cyclosilicate 10 g daily rather than stopping RASi 1
• Dietary counseling: Low-potassium diet (<2-3 g/day) 1

9. For Hyperphosphatemia 2

• If phosphate >4.5 mg/dL and eGFR <45 ml/min/1.73 m²: Start phosphate binder with meals (e.g., calcium acetate 667 mg, 2 tablets three times daily with meals OR sevelamer 800 mg three times daily with meals) 2

10. For Vitamin D Deficiency 2

• If 25-OH vitamin D <30 ng/mL: Ergocalciferol 50,000 IU weekly for 8-12 weeks, then 1000-2000 IU daily 2

11. For Anemia 2

• If hemoglobin <10 g/dL: Check iron studies, B12, folate; consider erythropoiesis-stimulating agent if iron replete 2

Dietary and Lifestyle Orders

• Dietary consultation: Protein 0.8 g/kg/day (avoid >1.3 g/kg/day), sodium <2 g/day (<5 g sodium chloride/day) 3
• Mediterranean-style plant-based diet for cardiovascular risk reduction 1
• Physical activity prescription: Moderate-intensity exercise 150 minutes per week, avoid sedentary behavior 3
• Smoking cessation counseling if applicable 2
• Limit alcohol intake 1

Monitoring Orders

• Recheck labs in 2-4 weeks: Serum creatinine, eGFR, potassium after any RASi initiation or dose change 1
• Recheck labs in 3 months: Complete metabolic panel, urine ACR, CBC 2
• Ongoing monitoring every 3-6 months: eGFR, electrolytes, urine ACR, CBC depending on CKD stage 2
• Annual monitoring: Lipid panel, HbA1c (if diabetic), PTH (if eGFR <45), vitamin D 2

Medication Avoidance Orders

• Avoid NSAIDs (nephrotoxic) - document allergy alert in chart 2
• Avoid combination of ACEi + ARB + direct renin inhibitor 3
• Adjust antibiotic and oral hypoglycemic dosing for renal function 2

Nephrology Referral Criteria

• Urgent nephrology referral if: eGFR <30 ml/min/1.73 m², ACR ≥300 mg/g, rapid eGFR decline (>5 ml/min/1.73 m² per year), or uncontrolled hyperkalemia 2, 5

Common Pitfalls to Avoid

• Do NOT stop RASi when eGFR falls below 30 ml/min/1.73 m² - continue unless specific contraindications 1, 3
• Do NOT stop SGLT2i for reversible eGFR dip after initiation - this is expected and beneficial 1, 3
• Do NOT immediately discontinue RASi for hyperkalemia - first attempt potassium-lowering measures 1, 3
• Do NOT use high-protein diets in CKD patients at risk of progression 3