Pathways and Stages Kidney disease pathway hematuria pathway diabetes pathway non-diabetic MRP CKD stages referral sheet
    Disclaimer: The information and data in this document ("Information") is based on scientific evidence current as of the date issued and is subject to change without notice. The Information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Any person consulting or applying the Information is expected to use independent medical judgment and expertise in the context of individual clinical circumstances. Winnipeg Regional Health Authority and the Manitoba Renal Program make no representation or guarantees of any kind whatsoever regarding the content or use or application of the Information and specifically disclaim any responsibility for its application or use in any way.

eGFR & Referral Pathways

In fall of 2010, Manitoba Renal Program began implementing GFR reporting province-wide to track the kidney health of patients and encourage prevention and early detection of Chronic Kidney Disease. Health-care providers can follow the links on the left for information to assist you in navigating the various referral pathways and management guidelines. Resources available also include information on CKD disease stages and therapeutic zones.

Automatic Estimated Glomerular Filtration Rate (eGFR) reporting was introduced in Manitoba as per current Canadian Society of Nephrology guidelines to assist practitioners in the early identification of kidney disease. In patients with significantly impaired kidney function (i.e. <30 ml/min) eGFR adequately predicts these patient to be at increased RISK for End Stage Renal Disease (ESRD). However, it is recognized that in patients with milder degrees of kidney impairment (i.e. >30 ml/min), eGFR alone is often insufficient to predict the RISK of progression.

Newer recommendations in 2012 from the Kidney Dialysis Improving Global Outcomes (KDIGO) group have endorsed predicting risk for outcome of chronic kidney disease to guide decisions for testing and treatment of CKD complications. The Manitoba Renal Program has started using a calculator* to better identify patients at increased RISK for progression to End Stage Renal Disease, especially in patients with eGFR’s from 30-60 ml/min. This calculator requires the following information:

• Age and Sex
• Creatinine/Estimated GFR (eGFR) – preferably two values
• Urine albumin:creatinine ratio
• Calcium, Phosphate, Albumin, Total CO2

In considering a Nephrology consult for your patient, we request providing us with the above information. We also require your patients past medical history, medications list and urinalysis which aid the triaging process in appropriately risk stratifying each consult.

Using the risk prediction calculator, we define a patient’s overall risk for developing End Stage Renal Disease over five years. Those at intermediate or high risk are identified and assessed accordingly. Those that have a <3% predicted risk of developing ESRD over five years are felt to be low risk and as a result, nephrology referral may currently not be indicated.

This can be illustrated by the following example:

Two female patients 75 years old each with eGFR of 45 ml/min and a history of hypertension. A urine ACR for patient A is 10 mg/mmol and patient B is 100 mg/mmol. Patient A is found to be at 1.9% and patient B at 4.2% risk of progression to ESRD in 5 years.

Therefore, the consult on patient A would be returned as low risk with appropriate guidelines and patient B would be booked for routine assessment by nephrology.

Please follow the following link to the Kidney Failure Risk Equation* for additional information and feel free to utilize it in deciding on whether your patient may require a referral. Do not hesitate to contact us with questions at any time.

* Tangri N, Stevens LA, Griffith J, et al. A predictive model for progression of chronic kidney disease to kidney failure. JAMA. 2011;305(15). DOI:10.001/jama.2011.451


Videos

These videos have been developed as tools to help health-care providers discover and utilize the new Manitoba Renal Program eGFR pathways and management guidelines.