Chronic Kidney Disease (CKD)

Chronic Condition Management

Tip of the Month

Message from the Medical Director

In recognition of National Kidney Month in March, we are sharing chronic kidney disease (CKD) clinical guidelines. According to the CDC, more than 1 in 7, or about 15% of US adults, are estimated to have CKD, and 9 out of 10 adults with CKD are unaware of their diagnosis.

I encourage you to refer to the resources shared in this month's issue to support you in caring for your patients living with CKD.

Thank you for your commitment to delivering high-quality care to our patients and in support of their health.

Kind regards,

X. Shirley Chen, MD, MS

In this Issue

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CKD Staging and Risk Stratification
Screening and diagnostic testing: which tests and how often to order
Management and Preventative Care for CKD
When to Refer to Nephrology
ICD-10 coding for CKD

Clinical Takeaways

CKD Staging and Risk Stratification

Chronic kidney disease is defined as any abnormality of kidney function or structure lasting >90 days.

Early diagnosis and risk stratification of patients with CKD is essential to preventing disease progression.

Click the image to the left to view a visual categorization of CKD staging and evidence-based therapies at each stage.

Screening and Diagnostic Testing for CKD Management

Perform an ACR at least annually

Order eGFR and albuminuria testing via a urine albumin to creatinine ratio (uACR) at least annually to determine disease progression
Note: an annual eGFR and uACR is needed for the quality measure, Diabetic Kidney Health Evaluation
eGFR is calculated via a blood test, basic or comprehensive metabolic panel (BMP or CMP)
eGFR should be calculated based on serum creatinine, age, gender (typically on lab report; do not adjust by race)

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Use KidneyIntelX ^TM prognostic testing where available to identify and predict early stage disease (CKD stage 1, 2, and 3) progression for patients with Type 2 Diabetes

Screen at least annually

for:

Metabolic acidosis
Hyperkalemia
Anemia
Lipids

Screen for bone metabolic disease as needed*:

Vitamin D
Calcium
Phosphate
PTH

*typically beginning at stage 3 CKD

Management and Preventative Care for CKD

Comorbidity	Next Step
Hypertension	Achieve target blood pressure control <130/80
Persistent albuminuria (UCR >30)	Prescribe an ACE/ARB and titrate to maximum tolerated dose. For medications, please see the CKD Quick Reference Guide.
Diabetes with CKD and eGFR >30	Prescribe SGLT2i along with metformin as first-line therapy to achieve glycemic control. Medications and Starting Doses: Dapaglifozin 10mg daily Empagliflozin 10mg daily Canagliflozin 10mg daily
Diabetes with CKD — SGLT2i intolerant and eGFR >15	Prescribe GLP-1 RA Medications and Starting Doses: Semaglutide 0.25mg SubQ once weekly or 3mg oral daily Dulaglutide 0.75mg SubQ once weekly Liraglutide 0.6mg SubQ daily

When to Refer to Nephrology

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Consider a nephrology referral for the following indications:

Clarify cause of CKD and/or assistance managing related complications, AKI, or abrupt sustained fall in GFR
All advanced stage 4-5 CKD (GFR <30), urine ACR >300 mg/g

Resistant hypertension, persistent hyper-/hypokalemia, hyperphosphatemia, refractory anemia
Planning for or initiation of dialysis (if risk of kidney failure within next year is ≥10-20%)
Transplantation should be considered if GFR <20 with likely progressive, irreversible CKD over next 6-12 months

ICD-10 Coding for CKD

Ensure that your patients' true levels of complexity are accurately reflected by using accurate and specific documentation and coding.

This is not only essential to performance in value-based care reimbursement but also helps ensure that future quality of care and appropriate support services are made available.

Code for all stages of CKD to the maximum level of specificity possible at least once each calendar year, accounting for any progression of disease:

Stage	ICD-10
1	N18.1
2	N18.2
3a	N18.31
3b	N18.32
4	N18.5
5	N18.5
End Stage Renal Disease	N18.6

For patients with coexisting diabetes, ensure that Diabetes with Complications is documented using appropriate diagnosis codes:

Complication	ICD-10
Type II Diabetes with CKD (specify stage)	E11.22
Type II Diabetes with microalbuminuria	E11.29
Type II Diabetes with nephropathy	E11.21

Type II Diabetes begins with E11.-

Type I Diabetes begins with E10.-

For any questions about coding and documentation, please email Donna Malone, Director of Clinical Documentation and Quality Improvement.

Mount S in ai CKD Qu ic k Refere n c e Gu i d e

Managing CKD in Primary Care

The CKD quick reference guide is designed specifically for primary care physicians and includes clinical guidelines developed with key nephrology leadership. What’s inside:

Checklist for CKD management
Treatments: pharmacological, diet and lifestyle
Managing common comorbidities
Commonly-used medications

Find more on the Chronic Condition Management Hub

Mount Sinai Health System's Chronic Condition Management Hub is an online resource center for primary care physicians, specialists, and other care providers with resources and information to help them manage chronic health conditions

P: 877-234-6667

E: MSHP@mountsinai.org

Provider Engagement Team