Sample Doctor's Orders for Chronic Kidney Disease
For a patient with CKD, initiate a multi-drug regimen prioritizing SGLT2 inhibitors, RAS inhibitors (ACEi or ARB), and statins, with specific orders tailored to the patient's eGFR, albuminuria status, and comorbidities. 1, 2
Diagnostic Orders
Initial Laboratory Assessment
- Serum creatinine with eGFR calculation (using CKD-EPI equation) 1
- Urine albumin-to-creatinine ratio (UACR) - collect 2 of 3 specimens over 3-6 months to confirm albuminuria due to >20% biological variability 1
- Complete metabolic panel including potassium, bicarbonate, calcium, phosphorus 1, 3
- Complete blood count to assess for anemia 3
- Lipid panel (fasting) 1
- Hemoglobin A1c if diabetic 1
- Parathyroid hormone (PTH) and 25-hydroxyvitamin D if eGFR <45 mL/min/1.73 m² 3
Monitoring Schedule
- Recheck serum creatinine, potassium, and bicarbonate 2-4 weeks after initiating or increasing dose of RASi 1
- Annual UACR for ongoing monitoring 1
- Blood pressure monitoring at every visit 1
Pharmacological Orders
First-Line: SGLT2 Inhibitor (Highest Priority)
- For Type 2 Diabetes with eGFR ≥20 mL/min/1.73 m²: Start SGLT2 inhibitor (e.g., empagliflozin 10 mg daily, dapagliflozin 10 mg daily, or canagliflozin 100 mg daily) 1, 2
- For CKD without diabetes with eGFR ≥20 mL/min/1.73 m² AND (UACR ≥200 mg/g OR heart failure): Start SGLT2 inhibitor 1
- For eGFR 20-45 mL/min/1.73 m² with UACR <200 mg/g: Consider SGLT2 inhibitor 1
- Continue SGLT2i 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
Second-Line: RAS Inhibitor
For CKD with diabetes and UACR ≥30 mg/g (A2 or A3):
- Start ACEi (e.g., lisinopril 10-40 mg daily, enalapril 10-40 mg daily) OR ARB (e.g., losartan 50-100 mg daily, irbesartan 150-300 mg daily) 1, 2
- Use maximum tolerated dose - proven benefits achieved at highest approved doses 1, 2
For CKD without diabetes:
Critical monitoring parameters:
- Continue RASi unless creatinine rises >30% within 4 weeks of initiation or dose increase 1, 2
- Do NOT discontinue for minor creatinine increases ≤30% in absence of volume depletion 1
- Continue even when eGFR falls below 30 mL/min/1.73 m² 1, 2
- Manage hyperkalemia with potassium-lowering measures rather than stopping RASi 1, 2
- Never combine ACEi + ARB + direct renin inhibitor 2
Third-Line: Nonsteroidal Mineralocorticoid Receptor Antagonist
For Type 2 Diabetes with eGFR >25 mL/min/1.73 m², normal potassium, and UACR >30 mg/g despite maximum tolerated RASi:
- Start finerenone 10-20 mg daily (based on eGFR) 1, 2
- Can be added to RASi + SGLT2i combination 1, 2
- Monitor potassium regularly after initiation 1, 2
Lipid Management
For age ≥50 years with eGFR <60 mL/min/1.73 m²:
- Start statin or statin/ezetimibe combination (e.g., atorvastatin 40-80 mg daily + ezetimibe 10 mg daily) 1, 2
For age ≥50 years with eGFR ≥60 mL/min/1.73 m²:
For age 18-49 years with CKD and (coronary disease OR diabetes OR prior stroke OR 10-year CV risk >10%):
- Start statin 1
Blood Pressure Management
- Target systolic BP <120 mmHg when tolerated 2
- Use ACEi/ARB as first-line for hypertension in CKD 1, 4
- Add additional agents (dihydropyridine CCB, thiazide/loop diuretic) as needed to reach target 4
Glycemic Control (if Type 2 Diabetes)
If not at glycemic target despite metformin + SGLT2i:
- Add long-acting GLP-1 RA with proven CV benefits (e.g., dulaglutide 1.5 mg weekly, semaglutide 1 mg weekly) 1, 2
- Reduce metformin dose at eGFR <45 mL/min/1.73 m²; discontinue at eGFR <30 mL/min/1.73 m² 2
Antiplatelet Therapy
For established ischemic cardiovascular disease:
- Aspirin 81 mg daily 1
Dietary Orders
Protein Restriction
For CKD Stage 3-5 (eGFR <60 mL/min/1.73 m²) not on dialysis:
- Limit dietary protein to 0.8 g/kg/day (recommended daily allowance) 1, 2
- Avoid high protein intake >1.3 g/kg/day 2
For patients on dialysis:
- Higher protein intake recommended due to malnutrition risk 1
Sodium Restriction
- Limit sodium intake to <2 g/day (<5 g sodium chloride/day) 2
Other Dietary Modifications
- Consider plant-based Mediterranean-style diet for CV risk reduction 1
- Limit alcohol, meats, and high-fructose corn syrup to prevent gout 1
Lifestyle Orders
Physical Activity
Metabolic Complication Management
Acidosis
If serum bicarbonate <18 mmol/L:
Hyperuricemia
If symptomatic gout:
- Treat acute gout with low-dose colchicine or glucocorticoids (avoid NSAIDs) 1
- For chronic management, use xanthine oxidase inhibitor (allopurinol 100-300 mg daily, adjust for eGFR) 2
- Do NOT treat asymptomatic hyperuricemia 1
Referral Orders
Nephrology Referral
Mandatory referral for:
- eGFR <30 mL/min/1.73 m² 1
- Uncertainty about etiology of kidney disease 1
- Difficult management issues 1
- Rapidly progressing kidney disease 1
- UACR ≥300 mg/g 3
Common Pitfalls to Avoid
RASi Management
- Do NOT stop RASi for creatinine increases ≤30% - this is expected and acceptable 1
- Do NOT discontinue RASi when eGFR falls below 30 mL/min/1.73 m² - continue unless specific contraindications 1, 2
- Manage hyperkalemia medically first before reducing or stopping RASi 1, 2
SGLT2i Management
- The initial eGFR dip with SGLT2i is reversible and NOT an indication to stop 1, 2
- Continue SGLT2i even if eGFR falls below 20 mL/min/1.73 m² after initiation 1