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    Chronic Kidney Disease

    Identifcation, Evaluation and Management o PatientsE ective Date: e te e e te e

    Scope

    The st a t o this guideline ovides eco endations o the investigation and evaluation o adultatients ( 9+) at isk o ch onic kidney disease (CKD). The second a t o this guideline ocuses on

    the anage ent o adult atients with known CKD and includes ca e o jectives and atient sel -anage ent.

    ecialized anage ent o esta lished CKD e.g. e yth o oietic agents o ane ia enal e lace ent

    the a y and t eat ent o calciu hos hate o a athy oid ho one (PTH) a no alities is eyondthe sco e o this guideline.

    Diagnostic Code: (ch onic enal ailu e)

    Part 1: Identifcation and Evaluation o Patients at Risk or CKD

    This section cove s:I. P evention and isk acto sII. InvestigationIII. Diagnosis and staging o CKDIV. Dete ining the cause o CKD

    V. Evaluating atients with a no al sc eening tests VI. Flow diag a o evaluating and anaging sus ected CKD

    I. Prevention and risk actorsIdenti y atients at isk o CKD ased u on a di ected edical and su gical histo y including co-

    o idities (e.g. dia etes ca diovascula disease [CVD]) and dieta y social de og a hic andcultu al acto s a eview o sy to s and hysical exa ination. Po ulations at inc eased iskinclude those with: Dia etes Hy e tension with o without CVD A a ily histo y o kidney disease eci c high- isk ethnic g ou s: Fi st Nations Paci c Islande s A ican descent and Asians

    Note: Age > 6 yea s is associated with an inc eased isk o i ai ed kidney unction ut evidence isinsu cient to eco end sc eening solely on the asis o age.

    II. InvestigationIt is eco ended that hysicians sc een at- isk o ulations eve y - yea s de ending u onclinical ci cu stances (e.g. yea ly o e sons with dia etes) using se u c eatinine and andou ine tests ( ac osco ic/ ic osco ic u inalysis and ACR). Esti ated glo e ula lt ation ate

    BRITISHCOLUMBIA

    MEDICALASSOCIATION

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    (eGFR) is the est a ke o CKD and is co uted o the se u c eatinine. Most la s inB itish Colu ia (BC) auto atically e o t eGFR when a se u c eatinine is o de ed. ( ee

    A endix B o u the in o ation on eGFR calculations.)

    Investigational tests

    a) e u testing: eGFR values:

    < 6 L/ in and persistent ( esent o > 3 onths) indicates su stantial eduction in kidneyunction.

    > 6 L/ in and < L/ in in the a sence o u ine a no alities o st uctu ala no alities on i aging studies (e.g. ult asound) does not indicate kidney disease.

    Age > 7 yea s: accu acy o eGFR o atients ove 7 is questiona le and ayunde esti ate t ue kidney unction. Values o eGFR < 4 should e conside ed as a likelyindicato o dec eased enal unction and e it u the wo k-u . Values etween4 and 6 ay efect no al va iation in the a sence o othe conditions howeve caution isstill eco ended with es ect to edications dye and isk o acute kidney inju y with seve eillnesses. Co elation with clinical condition is eco ended.

    Age > yea s: equation o eGFR is o le atic and isk o og ession o CKD isnot known. In the a sence o othe eta olic o he atological a no alities a conse vativea oach is eco ended. Values etween 4 and 6 ay efect no al va iationin the a sence o othe conditions. Caution is still eco ended with es ect to

    edications dye and isk o acute kidney inju y with seve e illnesses. Esti ates ased on se u c eatinine easu e ents (eGFR) ay e un elia le in atients with

    ve y la ge o s all ody ha itus those on s eci c diets (ve y high o ve y low otein) and inatients eceiving edications that inte e e with the exc etion o c eatinine (e.g. t i etho i

    and sul a ethoxazole ci ofoxacin eno ate). Exe cise diet and/o hyd ation status ay a ect kidney unction esti ates o the deg ee

    o al u inu ia/ oteinu ia. I aseline tests a e a no al o su sequent tests a e signi cantlydi e ent o aseline con ation y e eat testing is wa anted.

    ) U ine testing: ac osco ic/ ic osco ic analysis and al u in/c eatinine atio (ACR) values Rando u ine tests o ac osco ic/ ic osco ic u inalysis and ACR: igni cant a no alities: e sistent white lood cells o ed lood cells in the a sence

    o in ection o inst u entation; esence o any cellula casts is always athological. ACR elevation (> . g/ ol ales; > . g/ ol e ales) on out o 3 se ial tests

    e o ed week to onths a a t indicates ic o-vascula disease +/- glo e uladisease.

    U ine test a no alities even with e sistent eGFR values 6 l/ in indicate a no alkidney unction eithe as an isolated condition o as a sy to o a syste ic disease.

    4-hou u ine collections a e not necessa y in ost cases. ACR is the ethod that allows one to test o al u in esent in quantities a ove no al

    ut elow the detecta le ange on standa d di sticks. In the ast the wo d ic oal u inhas een used ut this ay lead to a alse i ession that the e is a di e ent oleculewhen the e is not. Thus ACR is the e e ed ethod y which to assess a no allevels o al u in. Note that this guideline uses the th esholds ado ted y the CanadianDia etes Association o the detection o ic oal u inu ia. As ethods i ove and

    u the data eco es availa le these cuto s ay e evised. e ial ACR tests can no allye inco o ated into the outine visit schedule.

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    3/20C hroniC Kidney d isease identifiCation , e valuation and M anageMent of P atients Diagnostic Code:

    Stage Description

    1 Kidney damageb with normal or eGFR2 Kidney damageb with mild eGFR3 Moderate in eGFR4 Severe in eGFR5 Kidney ailure

    Acting on test esults

    No al: e eat annually o as clinically indicated and onito lood essu e. A no al: con and evaluate (Ta le elow).

    III. Diagnosis and staging o CKDCKD is de ned as eGFR < 6 L/ in o > 3 onths o evidence o kidney da age ( athologic

    a no alities o a ke s o da age including a no alities in lood o u ine tests o i agingstudies). I CKD is esent dete ine its stage ased on eGFR u inalysis and ACR. The ollowingstaging syste designed y the U National Kidney Foundation with inte national in ut is

    eco ended to acilitate assess ent and anage ent o CKD. 3

    Table 1. Stages o CKD

    Potential Complications of reduced eGFRa (alphabetically)

    Anemia, including unctional iron de ciency BP increases Calcium absorption decreases Dyslipidemia/heart ailure/volume overload Hyperkalemia Hyperparathyroidism Hyperphosphatemia Le t ventricular hypertrophy Metabolic acidosis Malnutrition potential (late)

    NOTE :a The listed co lications a e not s eci c to CKD ut tend to occu with inc easing equency and a e o e di ectly

    att i uta le to CKD at lowe eGFR (e.g. stages 4 and ). I co lications a e noted at an ea ly stage o CKDinvestigation o alte native causes is eco ended e.g. o ound ane ia at eGFR o l/ in is likely not

    att i uta le to low kidney unction alone.Kidney da age is de ned as athological a no alities (kidney io sy esults) o a ke s o da age includinga no alities in lood o u ine tests ( otein/al u in in the u ine ed lood cells white lood cells o casts) o i agingstudies.

    IV. Determining the cause o CKDI ai ed kidney unction is o ten ulti- acto ial. I ossi le dete ine a i a y cause okidney disease in all atients. Kidney ult asound is a use ul exa ination to identi y olycystickidney disease cance stones and o st uction. Disc e ancy in kidney size ay signal clinicallysigni cant enal a te y stenosis (the wo k u o enal a te y stenosis is eyond the sco e o thisguideline).

    Even i a i a y cause see s o vious (e.g. hy e tension dia etes) the ossi ility o a se iousunde lying diso de (e.g. vasculitis syste ic lu us e ythe atosis) ust e conside ed in atientswith:

    A no al u inalysis e.g. oteinu ia he atu ia cellula casts o co inations the eo . Ra id sustained decline in kidney unction ( eGFR > - %/yea ) des ite e edy o

    eve si le eci itants e.g. volu e cont action e ile illness edications. Consistent i ai ent o kidney unction in the a sence o isk acto s. Constitutional sy to s suggesting syste ic illness. udden o seve e onset o sy to s e.g. ede a un elated to hea t o live disease.

    eGFRa

    9060-8930-5915-29

    < 15 oron dialysis

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    Re e to an inte nist o ne h ologist o u the evaluation i an etiology cannot e dete ined.Note that occasionally a sc eening test will identi y a se ious syste ic disease o ea ly stageso an acute illness. In atients with active u ine sedi ents ( c casts o cellula casts otein)constitutional sy to s o unex lained seve ity o kidney dys unction o t consultation with as ecialist and/o e-evaluation o tests is indicated.

    V. Evaluating patients with abnormal screening tests

    Patient anage ent should efect CKD stage and eGFR u inalysis and ACR esults (see Ta le ).

    Table 2. Evaluating patients with abnormal screening testsEvaluating patients with abnormal screening tests a

    Stage Other Results Recommendations b

    Stage 1 or 2; eGFR 60mL/minplus evidence okidney damagec

    Stage 3; eGFR =30-59 mL/min

    Stage 4; eGFR =15-29 mL/min

    Stage 5; eGFR 20 male;> 28 emale)

    Urinalysis normalbut ACR equivocal(2-20 male; 2.8-28

    emale)

    Urinalysis abnormal or

    ACR abnormal(> 20 male;> 28 emale)

    Regardless o otherresults

    Regardless o otherresults

    Determine cause o CKD. See management advice in Part 2. Consider kidney U/S.d

    Order annual creatinine and urine tests. Consider re erral to nephrologist/interniste i urine protein is

    increasing, eGFR is declining > 10% annually, or serum K + is

    repeatedly > 6.0 mmol/L. See management advice in Part 2. Consider kidney U/S. Consider re erral to nephrologist/internist. Consider re erral to urologist or isolated microhematuria even

    i U/S is normal. See management advice in Part 2. Consider kidney U/S. Order annual creatinine and urine tests q 6 months. Consider re erral to nephrologist/internist i urine protein

    increasing or eGFR declining > 10%/year. See management advice in Part 2.

    Order kidney U/S. Consider re erral to nephrologist/internist.

    See management advice in Part 2. Re er to nephrologist/internist. See management advice in Part 2. Re er urgently to nephrologist/internist.

    KEY: ACR=albumin/creatinine ratio, CKD=chronic kidney disease, CVD=cardiovascular disease, eGFR=estimated glomerular ltration rate,K=potassium, U/S=ultrasound

    NOTE :a In the a sence o othe syste ic illness.

    All CKD atients a e at isk o CVD the e o e the usual otocols o CVD isk evaluation and t eat entshould e ollowed. 4

    c Patients with eGFR > 6 l/ in in the a sence o a no alities o u ine o i aging tests do not havetage o CKD. I the atient is in a high- isk o ulation e eated sc eening is eco ended at egula

    inte vals.d Kidney U/ ay e equi ed in those with a a ily histo y o olycystic kidney disease o sy to s o

    u ina y t act o st uction in ection o stones. It can also quickly identi y eve si le conditions.e Inte nists a e skilled in the initial wo ku and anage ent o ea ly CKD and given the usual conco itant

    association o CKD and CVD a e also a o iate as the initial e e al.

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    5/20C hroniC Kidney d isease identifiCation , e valuation and M anageMent of P atients Diagnostic Code:

    Figure 1. Flow Diagram or Evaluating and Managing Patients with Suspected CKD

    Part 2: Management o Patients with Established CKD

    This section cove s:I. Identi ying ca e o jectives and ta getsII. P actice oints o goal settingIII. u o ting atient sel - anage entIV. Meeting ca e o jectives

    I. Identi ying care objectives and targetsPhysicians will ideally identi y ca e o jectives o all atients with CKD (see Ta le 3). De endingon the level o kidney unction and co lexity o the a y equi ed these ca e o jectives ay e

    o e o less di cult to achieve without hel o a s ecialized tea o health ca e o essionalsincluding a ne h ologist. T eat ent goals ust e tailo ed to the individual.

    Identi y and screen populations at increased risk Asce tain the isk acto s. Pe o a syste s eview and hysical exa .

    O de la o ato y tests including se u c eatinine/eGFR and ando u ineo ac o/ ic o u inalysis and ACR ( ic oal u in). Re eat tests within 3 onths to con any a no al esults

    unless constitutional sy to s a e esent and equi e o e u gentinvestigation anage ent and e e al.

    Follow-up tests are abnormal: Dete ine CKD stage ased on

    eGFR u inalysis and ACR. Dete ine cause o kidney

    disease. A ange ongoing ollow-u ( ee

    Ta le ). ee ca e o jectives in Pa t

    ( ee Ta le 3).

    Follow-up tests are normal: Monito annually o as clinically

    indicated ( ee Ta le 3).

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    6/20ChroniC Kidney d isease identifiCation , e valuation and M anageMent of P atientsDiagnostic Code:

    BP < 130/80. ACEI/ARB recommended in

    addition to other drugs.*

    Stability o kidney unction or< 10-15% decline in eGFR annua Reduce abnormal values by

    50% or more rom baseline ACEI/ARBs recommended.*

    Reduce risk in those at highrisk.

    Lipid targets ( 110- 125 g/L i on

    treatment. Trans errin saturation > 20% Calcium 2.2-2.5 mmol/L. Phosphorus 0.75-1.4 mmol/L iPTH in normal range.5 Albumin in normal range.Prevention o infuenza.

    Prevention o pneumonia.

    Seroconversion, prevention oHep B (seroconversion rate highi immunized early).6

    Avoidance o aminoglycosides,

    NSAIDs, COX-2 inhibitors,intravenous or intra-arterialradiocontrast studies. Providing support. Optimize sel -management.

    BP

    Kidney unctionmeasurements

    Urine testing

    Monitor serumelectrolytes

    CVD riskassessment &lipid pro les

    Diabetes: Bloodglucose controlover time

    Weight &nutritionSmoking Assessment oconditionsassociated with

    CKD

    Flu vaccinePneumococcalvaccine Awareness oHepatitis B risk

    Limit exposure

    to nephro-toxins/drugadjustmentsPsychosocialhealth

    Table 3: Care objectives and targets

    Care Objective Target

    Measure and record at diagnosis and at every visit therea ter. See BC guideline:Hypertension Detection, Diagnosis and Management at www.BCGuidelines.ca

    Obtain regular measurements o serum creatinine or eGFR (at least q 6 months)and a ter any change in medications, medical intervention, or clinical status.

    ACR (microalbumin) every 6-12 months or as clinically indicated.

    Measure a ter change in medications, medical intervention, or clinical statuswith particular attention to K +.

    Check serum creatinine and K + prior to starting ACEIs and ARBs, within 2weeks o starting, and within 2 weeks a ter dose increase.

    Serum creatinine rise >20% or eGFR decrease >15% a ter dose increaseshould be ollowed by urther measurements within 2 weeks.

    Calculate & record CVD risk. Manage in accordance with relevant guidelines. Check asting lipids yearly once target values are achieved & more requently

    in patients on lipid lowering medication. Measure A1C q 3 months or as clinically indicated. SeeDiabetes Care guideline

    at www.BCGuidelines.ca Long-acting sul onylureas may be associated with hypoglycemia with unstable

    eGFR, especially those below 45. I recurrent hypoglycemia, or unstable eGFRconsider using short-acting sul onylureas or non-sul onylureas.

    In those with unstable eGFR or acute changes in clinical condition, met orminshould be held.

    Record weight & BMI on each visit or comparison.

    Encourage patient to stop smoking, enquire at every visit, support when receptive.Measure at least yearly (more requently with advanced CKD): CBC. Mineral metabolism (calcium, phosphorus, iPTH).

    Nutrition pro le (albumin).

    Immunize annually.Immunize every 10 years.

    Immunization at a higher level o eGFR more likely to result in seroconversioni patient is being considered or hemodialysis. Screening and vaccination inconsultation with nephrology team. Reduce risk o acute or chronic deterioration o kidney unction.

    Adjust renally excreted drugs according to kidney unction.

    Depression and grie reaction may occur with chronic disease. Identi y and address psychosocial problems that a ect the illness.

    KEY: BP=blood pressure; A1C=glycated hemoglobin (previously HbA1C); ACEI=angiotensin-converting enzyme inhibitor; ARB=angiotensin II receptor ACR=albumin/creatinine ratio; BMI, body mass index; COX-2=cyclooxygenase-2; ESA=erythropoiesis-stimulating agent; eGFR=estimated glomerular ltHDL=high-density lipoprotein; Hgb=hemoglobin; iPTH=intact parathyroid hormone; LDL=low-density lipoprotein; NSAID, non-steroidal anti-infammatoryTC=total cholesterol.NOTES FOR TABLE 3: * Reduction o proteinuria can be acilitated by the use o ACEI/ARBs. This has been shown to reduce the rate o

    insu ciency in hypertensive patients with diabetes or chronic glomerulonephritis.7,8

    In severe CKD (eGFR < 15ml/min), weight loss may indicate a catabolic state and a possible need or dialysis.

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    II. Practice points or goal settingWhen setting goals with you atient conside the ollowing: Exe cise diet and/o hyd ation status ay a ect kidney unction esti ates o the deg ee

    o al u inu ia/ oteinu ia. I aseline tests a e a no al o su sequent tests a e signi cantlydi e ent o aseline con y e eat testing.

    Rigo ous cont ol o BP has een shown to educe the isk o co lications and o tality ates.In a ticula the inhi ition o the enin angiotensin syste with ACE inhi ito s o ARBs has

    een shown to e ve y e ective. Diu etics - locke s and/o calciu channel locke say also e equi ed since ost atients equi e o e than two edications to each ta get

    values. 9 ee BC guideline: Hypertension Detection, Diagnosis and Management. Eve y adult with kidney disease ay e at inc eased isk o ca diovascula disease. 4

    Ne h otoxic edications (e.g. N AIDs COX- inhi ito s a inoglycosides) should e avoidedo used with caution in atients with even ild kidney i ai ent (eGFR 6 -9 L/ in withevidence o kidney da age) and kidney unction should e onito ed i they a e used.

    IV o int a-a te ial adiocont ast use oses a high isk o acute kidney inju y in atientswith tage 4 o CKD and a ode ate isk in atients with tage 3 disease. I i aging is

    equi ed alte nate i aging techniques including MRI angiog a hy should e conside edo these atients. I no alte native exists and the ocedu e is edically necessa y the atient

    should ovide w itten in o ed consent and otection with IV hyd ation and N-acetyl cysteineay e used acco ding to a u lished otocol o in consultation with ne h ologists.

    Patients with CKD a e at high isk o u the acute kidney inju y with volu e cont action e.g.nausea vo iting dia heal illnesses o the use o ce tain owel e a ations.

    Review edication list identi y edications exc eted y the kidneys (e.g. et o in digoxinand lithiu ) and adjust dosages as a o iate o use alte nate t eat ent. 3 (see PhysiciansResou ce section).

    Ra id dete io ation in kidney unction (a decline o eGFR > - % annually) wa ants u gente e al to a ne h ologist o inte nist.

    P e a ation o kidney e lace ent t eat ent equi es a ini u o onths the e o ee e al o conside ation o kidney e lace ent should take this into account.

    Many atients with CKD also have dia etes and/o hea t disease. Ex laining the linkage

    etween these conditions and how t eating one condition ene ts othe s ay lessen thesychological i act o seve al se a ate diagnoses. 4

    III. Supporting patient sel -managementPeo le with CKD have ette outco es i they take an active ole in the anage ent o thei owncondition and they should e encou aged to do so. Denial o ten associated with g ie eactionis co on in atients with ch onic disease a ecting a vital o gan. E o ts to int oduce eventiveli estyle and edical the a y ay ail until unde standing and acce tance have een achieved.CKD ca e tea s a e skilled at dealing with this issue.

    To su o t atient sel - anage ent the hysician should: u o t atients th ough the ocess o acce ting the diagnosis o a ch onic illness. Ensu e that atients unde stand the i lications o the diagnosis and thei ole in sel -

    anage ent. Hel atients identi y a su o t tea . Involve atients in de ning the est ossi le goals o ca e including li estyle odi cations

    such as s oking cessation healthy diets weight anage ent exe cise and social su o t. Encou age atients to onito thei own og ess th ough the use o dia ies o log ooks to

    t ack clinical values and sel - onito BP (and lood glucose whe e a o iate). Rein o ce li estyle odi cations at each visit. Ex lain and discuss the esults o investigations and consultations.

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    Identi y co unity esou ces that can ovide atients with the in o ation skills and su o tneeded to unde stand and anage thei condition and di ect o e e atients to those

    esou ces. Patient sel - anage ent esou ces a e listed in Chronic Kidney Disease: A Guide for Patients,

    a e availa le at www.BCGuidelines.ca

    IV. Meeting care objectives

    The ca e o CKD atients is ve y si ila to ca e o any atient with a ch onic illness thus si ilainci les should e a lied. Evidence indicates that the ca e o ch onic diseases such as CKD

    can e i oved y the i le entation o egula scheduled eviews o clinical and la o ato ya a ete s.

    Physicians a e encou aged to: C eate a atient egiste to identi y all atients with i ai ed kidney unction in thei actice. Pa tici ate in a co unity o ovincial atient egiste whe eve ossi le. Use a fow sheet o each atient with kidney disease. ( ee A endix C o sa le fow sheet.) Use an o ganized ecall syste to ensu e that la o ato y investigations and su sequent o ce

    eviews a e e o ed at egula ly scheduled a o iate inte vals. Review atient eco ds to ensu e ca e o jectives a e et.

    The e is inc easing evidence that at lowe levels o eGFR atients ene t o inclusion inultidisci lina y clinics. It is eco ended that i a y ca e hysicians seek o o tunities within

    thei co unities to ensu e these esou ces a e accessed. 6 7

    Rationale

    This guideline outlines st ategies that ay hel the i a y ca e actitione eet the co lexneeds o e sons with CKD including accu ate and ti ely diagnosis ex lo ation o its etiology anda o iate anage ent o co on acto s a ecting og ession and co- o id conditions.

    CKD is a se ious o ulation health o le with a signi cant i act on individuals a ilies societyand health se vices. It is o ten associated with othe co on ch onic diseases such as dia eteshy e tension and hea t disease. Based on o ulation studies the esti ated evalence o signi cantkidney i ai ent (eGFR < 6 l/ in) in B itish Colu ia is 4 eo le a oaching the

    evalence o Ty e II dia etes; howeve ecause any cases a e undiagnosed this is likely a t uesigni cant unde esti ate.

    The e is inc easing awa eness o CKD in all actices. CKD inc eases the isk o ca diac o idityand o tality to levels ten ti es that o o ulation ean isk in addition to lacing e sons at

    isk o end stage enal disease equi ing dialysis. 9 Recent studies have de onst ated that theesence o i ai ed kidney unction wo sens ognosis o length o hos ital stay o idity and

    o tality. 4 3Thus while not all eo le with kidney disease will equi e dialysis they a e all athighe isk o oo outco es adve se eactions to edications and inte ventions and e isodes oacute kidney ailu e. 4 4

    The outco e o atients who go on to dialysis e ains oo with ten e cent annual o tality; theove all ve-yea su vival ate is wo se than that o all cance s exce t cance o the lung. 6 Evidenceclea ly indicates that e o ts to cont ol hy e tension and oteinu ia (and hy e glyce ia in e sonswith dia etes) can event o ost one the develo ent o og essive kidney unction decline. 7

    7 93 3 3 3334Howeve levels o ca e o ilde stages o CKD e ain su o ti al and actitione so ten do not ovide sc eening and anage ent in acco dance with u lished guidelines. 3 36 37

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    The e cacy o statins in a o ulation with CKD is cu ently unde evaluation in the HARP t ial. 3 Untilthe esults a e e o ted asic isk eduction a oaches a e eco ended as ovided in the BCclinical actice guideline Cardiovascular Disease - Primary Prevention. 39 Fo eo le without hea tdisease a F a ingha isk- ased a oach to t eat ent with statins is suggested o eo le witha ten-yea co ona y hea t disease (CHD) isk o % o o e. T eat ent o the high isk o ulationshould e to an LDL ta get o . ol LDL/L o a atio o TC/HDL o < 4.

    The BC clinical actice guideline Diabetes Care eco ends a isk- ased a oach o li idanage ent with t eat ent to an LDL ta get o . ol/L o high- isk atients (> % CHD isk

    using the UKPD calculato ). 4 This a oach is consistent with the ecent A PEN t ial which showedno ene t using statins o eo le with low to ode ate isk o CHD (low isk % s oke s) 4 and theCARD t ial which showed a ene t o o ulation at highe - isk ( 3% s oke s). 4 Fo elde ly atients(7 + yea s) the PRO PER t ial ound that statins did not educe CHD and st oke events in en andwo en without CHD. 43

    Re erences

    . Gill J Malyuk R Dju djev O et al. Use o GFR equations to adjust d ug doses in an elde ly ulti-ethnicg ou a cautiona y tale. Ne h ol Dial T ans lant 7; ( ): 94-9.

    . National Kidney Foundation. K/DOQI clinical actice guidelines o ch onic kidney disease: evaluationclassi cation and st ati cation. A J Kidney Dis ;39( ) u l : - 66.

    3. Levey A Atkins R Co esh J et al. Ch onic kidney disease as a glo al u lic health o le :a oaches and initiatives a osition state ent o Kidney Disease I oving Glo al Outco es.Kidney Int 7;7 (3): 47- 9.

    4. a nak MJ Levey A choolwe th AC et al. Kidney disease as a isk acto o develo ento ca diovascula disease: a state ent o the A e ican Hea t Association Councils on Kidneyin Ca diovascula Disease High Blood P essu e Resea ch Clinical Ca diology and E ide iology andP evention. Ci culation 3; ( 7): 4-69.

    . Levin A Bak is G Molitch M et al. P evalence o a no al se u vita in D PTH calciu andhos ho us in atients with ch onic kidney disease: esults o the study to evaluate ea ly kidney

    disease. Kidney Int 7;7 :3 - .6. Da Roza G Loewen AH Dju djev O et al. tage o CKD edicts se oconve sion a te he atitis B

    i unization: ea lie is ette . A J Kidney Dis 3;4 (6): 4-9 .7. T ivedi H Pang MM Ca ell A et al. lowing the og ession o ch onic enal ailu e: econo ic

    ene ts and atients e s ectives. A J Kidney Dis ;39:7 -9.. Coyle D Rod y R o oka et al. Cost-e ectiveness o i esa tan 3 g given ea ly ve sus late in

    atients with hy e tension and a histo y o ty e dia etes and enal disease: a Canadian e s ective.Clin The 7; 9(7): - 3.

    9. Guidelines and P otocols Adviso y Co ittee. Hy e tension Detection Diagnosis and Manage ent.[Clinical P actice Guideline]. Availa le o www.BCGuidelines.ca. Accessed August .

    . Go A Che tow GM Fan D et al. Ch onic kidney disease and the isks o death ca diovascula eventsand hos italization. N Engl J Med 4;3 ( 3): 96-3 .

    . Te el M van de Giet M chwa z eld C et al. P evention o adiog a hic-cont ast-agent-inducedeductions in enal unction y acetylcysteine. N Engl J Med ;343(3): -4.

    . Ko enda P Zaluna do N Bu nett et al. Conse vative out atient eno otective otocol in atientswith low GFR unde going cont ast angiog a hy: a case se ies. Clin Ex Ne h ol 7; (3): 9- 3.

    3. Ka el J Calissi P. Ne h ology: 3. a e d ug esc i ing o atients with enal insu ciency. CMAJ; 66(4):473-7.

    4. Ko enda P Levin A. Analysis o ca diovascula disease and kidney outco es in ultidisci lina ych onic kidney disease clinics: co lex disease equi es co lex ca e odels. Cu O in Ne h olHy e tens 6; ( ):6 -6.

    . Goldstein M Yassa T Dacou is N et al. Multidisci lina y edialysis ca e and o idity and o tality oatients on dialysis. A J Kidney Dis 4;44(4):7 6- 4.

    6. Cu tis BM Ravani P Mal e ti F et al. The sho t- and long-te i act o ulti-disci lina y clinics in

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    Diagnostic Code:

    addition to standa d ne h ology ca e on atient outco es. Ne h ol Dial T ans lant ; ( ): 47- 4.7. He elga n BR Manns BJ Zhang J et al. Association etween ultidisci lina y ca e and su vival o

    elde ly atients with ch onic kidney disease. J A oc Ne h ol 7; (3):993-9.. tevens L A Coo e ingh et al. Detection o ch onic kidney disease in non-ne h ology actices:

    an i o tant ocus o inte vention. BCMJ ;47(6):3 - .9. Val ad id CT Klein R Moss E et al. The isk o ca diovascula disease o tality associated with

    ic oal u inu ia and g oss oteinu ia in e sons with olde -onset dia etes ellitus. A ch Inte n Med; 6 ( ): 93- .

    . Canadian Institute o Health In o ation. CORR e o ts t eat ent o end-stage o gan ailu e inCanada 99 to 4 ( 6 Annual Re o t). 7 Fe ua y [ 3 ages]. Availa le o htt ://secu e.cihi.ca/cihiwe /dis Page.js ?cw_ age=PG_7 _E&cw_to ic=7 &cw_ el=AR_ _E# ull. Accessed

    August 4 .. Culleton BF La son MG Wilson PW et al. Ca diovascula disease and o tality in a co unity- ased

    coho t with ild enal insu ciency. Kidney Int 999; 6(6): 4- 9.. Cu tis BM Pa ey P . How can the ca diac death ate e educed in dialysis atients? e in Dial

    ; ( ): - 4.3. Hu h ies K tigant C Levin A et al. Outco es a te e cutaneous co ona y inte ventions in atients

    with CKD: i oved outco e in the stenting e a. A J Kidney Dis ;4 (6) -9.4. Levin A. P evalence o ca diovascula da age in ea ly enal disease. Ne h ol Dial T ans lant ; 6

    u l :7- .. He elga n BR Zhang J Manns BJ et al. P og ession o kidney dys unction in the co unity-

    dwelling elde ly. Kidney Int 6;69( ): -6 .6. A un C todda t J Mackin P et al. igni cance o ic oal u inu ia in long-du ation ty e dia etes.

    Dia etes Ca e 3; 6(7): 44-9.7. Dia etes Cont ol and Co lications T ial Resea ch G ou . The e ect o intensive t eat ent o dia etes

    on the develo ent and og ession o long-te co lications in insulin-de endent dia etes ellitus.N Engl J Med 993;3 9( 4):977-9 6.

    . Modi cation o the Diet in Renal Disease tudy G ou . The e ects o dieta y otein est iction andlood- essu e cont ol on the og ession o ch onic enal disease: odi cation o diet in enal disease

    study g ou . N Engl J Med 994;33 ( 3): 77- 4.9. Dia etes Cont ol and Co lications T ial (DCCT) Resea ch G ou . E ect o intensive the a y on

    develo ent and og ession o ne h o athy in the DCCT. Kidney Int 99 ;47: 7 3- .3 . Bak is GL. Lowe lood essu e goals o atients with dia etes: the National Kidney Foundation

    consensus e o t. J Clin Hy e tension ;369-7 .3 . Hea t Outco es P evention Evaluation (HOPE) tudy Investigato s. E ects o a i il on

    ca diovascula and ic ovascula outco es in eo le with dia etes ellitus: esults o the HOPE studyand MICRO-HOPE su study. Lancet ;33 (9 ): 3-9.

    3 . RENAAL tudy Investigato s. E ects o losa tan on enal and ca diovascula outco es in atients withty e dia etes and ne h o athy. N Engl J Med ;34 ( ): -6 .

    33. Duncan L Heathcote J Dju djev O et al. c eening o enal disease using se u c eatinine: who a ewe issing? Ne h ol Dial T ans lant ; 6( ): 4 -6.

    34. ACE Inhi ito s in Dia etic Ne h o athy T ialist G ou . hould all atients with ty e I dia etes ellituseceive angiotensin-conve ting enzy e inhi ito s? A eta-analysis o individual atient data. Ann Inte n

    Med ; 34( ):37 -9.3 . Valde a no F Gol e T Mui head N et al. Ch onic kidney disease: why is cu ent anage ent

    uncoo dinated and su o ti al? Ne h ol Dial T ans lant ; 6 u l 7:6 -4.36. Powe NR. Ea ly e e al in ch onic kidney disease: An eno ous o o tunity o evention. A J

    Kidney Dis 3;4 ( ): -7.37. tigant C tevens L Levin A. Ne h ology: 4. t ategies o the ca e o adults with ch onic kidney

    disease. CMAJ 3; 6 ( ): 3-6 .3 . HARP tudy o Hea t and Renal P otection. Clinical t ial in o ation availa le at www.sha in o.o g

    Accessed August 4 .39. Guidelines and P otocols Adviso y Co ittee. Ca diovascula Disease P i a y P evention. [Clinical

    P actice Guideline]. Availa le at www.BCGuidelines.ca. Accessed August 4 .

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    Diagnostic Code:

    Contact In ormation

    Guidelines and P otocols Adviso y Co itteePO Box 964 TN PROV GOVT Victo ia BC V W 9PTele hone: 9 - 347 E- ail: [email protected] c.caFax: 9 - 4 7 We site: www.BCGuidelines.ca

    4 . Guidelines and P otocols Adviso y Co ittee. Dia etes Ca e. [Clinical P actice Guideline]. Availa le atwww.BCGuidelines.ca. Accessed August 4 .

    4 . Kno RH dE den M ilde JG et al. E cacy and sa ety o ato vastatin in the evention oca diovascula end oints in su jects with ty e dia etes: the Ato vastatin tudy o P evention oCo ona y Hea t Disease End oints in non-insulin-de endent dia etes ellitus (A PEN). Dia etes Ca e

    6; 9(7): 47 - .4 . Colhoun H Bette idge DT Du ington PN et al. 4. P i a y evention o ca diovascula disease

    with ato vastatin in ty e dia etes in the Colla o ative Ato vastatin Dia etes tudy (CARD ):ulticent e ando ised lace o-cont olled t ial. Lancet 4;364(943 ):6 -96.

    43. he he d J Blauw GJ Mu hy MB et al. P avastatin in elde ly individuals at isk o vascula disease(PRO PER): a ando ised cont olled t ial. Lancet ;36 (9346): 6 3-3 .

    This guideline is ased on scienti c evidence cu ent as o the E ective Date.

    This guideline was develo ed y the Guidelines and P otocols Adviso y Co ittee a oved y theB itish Colu ia Medical Association and ado ted y the Medical e vices Co ission.

    The inci les o the Guidelines and P otocols Adviso y Co ittee a e to:

    encou age a o iate es onses to co on edical situations eco end actions that a e su cient and e cient neithe excessive no de cient e it exce tions when justi ed y clinical ci cu stances.

    Appendices

    A endix A Physician Resou ces A endix B Calculating eGFR: Conve sion Ta le A endix C Ch onic Kidney Disease Flow heet A endix D Ch onic Kidney Disease A Guide o Patients

    Associated Documents

    The ollowing docu ents acco any this guideline: u a y

    Disclaimer

    The Clinical P actice Guidelines (the Guidelines) have een develo ed y the Guidelines and P otocols Adviso yCo ittee on ehal o the Medical e vices Co ission. The Guidelines a e intended to give an unde standingo a clinical o le and outline one o o e e e ed a oaches to the investigation and anage ent o the

    o le . The Guidelines a e not intended as a su stitute o the advice o o essional judg ent o a health ca eo essional no a e they intended to e the only a oach to the anage ent o clinical o le s.

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    Location Hospital Clinic Name Phone Number

    A ots o d F ase Health Kidney Ca e Clinic ..................................... 6 4 -3 74

    Ka loo s RIH Kidney Clinic ............................................. 3 4- 49

    Kelowna KGH Renal Health Clinic ...................... 6 -43 ext 33 6

    u ey MH Kidney Ca e Cent e ................................... 6 4 7-763

    Penticton PRH Renal Health Clinic (P e-dialysis) .............. 77 - 7

    P ince Geo ge PGRH Out atient Renal Clinic ............................. 6 - 747

    T ail Ki o Wellness Cent e Kidney Ca e Clinic ..................................... 364-34

    Vancouve t. Pauls Kidney Function Clinic .............................. 6 4 6-9

    Vancouve VGH He odialysis Unit ..................................... 6 4 7 -4

    Victo ia RJH Kidney Ca e Clinic ....... 37 - 4 o 37 - 4

    BC Provincial Renal Agency (BCPRA)PH A uite 7 - 3 Bu a d t eet Vancouve BC V6Z H3Phone: 6 4 7 -734 ; Fax: 6 4 7 -7366; www. c enalagency.ca

    The BC P ovincial Renal Agency is a colla o ative o enal health o essionals who coo dinates the ca eo atients with kidney disease in BC.

    Kidney Foundation o Canada (BC Branch)6 4 736-977 (Vancouve a ea) 67- (elsewhe e in BC); Fax: 6 4 736-97 3www.kidney. c.ca; e- ail: in [email protected] c.ca

    The Kidney Foundation ovides educational ate ials elated to va ious as ects o kidney disease andt eat ent and o e s a nu e o atient se vices. The Foundation has acilitated educational sessions onch onic kidney disease o a ily hysicians. Fo o e in o ation lease e e to the We site o contactthe BC B anch.

    National Kidney Foundation (USA)The National Kidney Foundation We site www.kidney.o g includes a section o health ca e

    o essionals as well as on-line access to the K/DOQI guidelines.

    Further in ormation on nephrotoxic drugsKa el J Calissi P. Ne h ology: 3. a e d ug esc i ing o atients with enal insu ciency. CMAJ

    ; 66(4):473-477

    www. note ook.co /Renal/Pha /N h txcD gs.ht

    P hysiCian r esourCes

    Chronic Kidney Disease

    B C R e n a l A g e n c yAn Agency of the Provincial Health Services Authority

    E ective Date: e te e e te e

    BRITISHCOLUMBIA

    MEDICAL

    ASSOCIATION

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    Stage 1 = > 90 ml/min with abnormalities on UA or USStage 2 = 60 89 ml/min with abnormalities on UA or USStage 3 = 30 59 ml/minStage 4 = 15 29 ml/minStage 5 =

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    m en a ge ( years )

    -C eatinine -39 4 -49 - 9 6 -69 7 -79

    4 49 9 76 69 63 9 9 4 34 3 6 3

    6 69 7 4 7 79 6 9 94 9 6

    9 9 7 76 749 99 74 7 69 67 6

    9 7 66 64 6 6 9 6 6 7 4 9 9 4 49 4

    3 39 4 4 46 4 44

    4 49 46 44 4 4 4 9 46 4 4 39 3 37

    6 69 43 39 3 36 3 37 79 4 37 3 34 33 3

    9 37 34 33 3 3 39 99 3 3 3 3 9 9

    9 33 3 9 7 9 3 9 7 6 9 3 7 6 6 4

    3 39 6 4 4 34 49 7 4 3

    9 6 4 3 6 69 3 7 79 4 9

    9 3 9 9 9 99 9 9

    Stage 1 > 90 ml/min with abnormalities on UA or USStage 2 = 60 89 ml/min with abnormalities on UA or USStage 3 = 30 59 ml/minStage 4 = 15 29 ml/min

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    CHRONIC KIDNEY DISEASE FLOW SHEET

    ME OF PATIENT

    This Flow heet is ased on the Guideline Ch onic Kidney DiseaseWe site: htt ://www. cguidelines.ca

    DATE OF BIRTHEX

    M F

    K FACTOR AND CO-MORBID CONDITION

    DATE

    BP WEIGHT

    L s Kg

    LABS ( ost ecent)

    VISITS

    ANNUALLY OR AS CLINICALLY INDICATED

    CARE OBJECTIVES

    HLTH/BCMA 6 (REV. / )

    SELF MANAGEMENT (Discuss with patient)

    Dia etes

    HTN

    CAD

    Ca dio yo athy

    CHF

    A1C Cr/eGFR ACR

    oke

    Alcohol/ u stance a use

    O esity (ta get BMI < )

    Othe :

    REMINDERS: 1) ESTABLISH REGULAR VISIT AND LAB WORK SCHEDULE2) REFER TO NEPHROLOGY TEAM 3) *

    Annual Flu: Pneu ovax (q y):

    VACCINATIONS

    DATE DATE DATE

    NOTE : CLINICAL TATU CARE OBJECTIVE AND FOLLOW-UP I UE

    Guidelines &Protocols

    Advisory Committee

    AGE AT DIAGNO I

    At ial ilation

    Othe a hyth ia

    Valvula HD

    PVD

    Li id a no ality

    < 3 / BMI < 7% ta le *

    %

    oaseline

    eve y visit eve y visit(DM only)

    q3 q6q6-

    LAB WORK (at least annually)

    He atitis B (se ies co leted):

    DATE

    Ex lain diagnosis and i lications o CKD

    el onito with fow sheet

    Review edication list (see eve se)

    Discuss CVD isk assess ent & anage ent st ategies

    Kidney-s eci c education

    Identi y su o t tea and esou ces

    oking cessation: Quit Now 77 4 - 33

    Weight exe cise and nut ition status

    P o ote sychosocial health

    RENAL U/(IF INDICATED) DATE:HTN

    OTHER: RE ULT:

    YPE OF CKD: DMPOLYCY TIC KD

    LIPIDS

    HgbWNR/ -

    on tx

    LDL< . high-isk (

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    MEDICATIONNAME OF DRUG PRE CRIBED BYDO E /FREQUENCY NOTE AND TART/ TOP DATE

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    Chronic Kidney Disease a g uide for P atients

    B C R e n a l A g e n c yAn Agency of the Provincial Health Services Authority

    BRITISHCOLUMBIA

    MEDICALASSOCIATION

    E ective Date: e te e e te e

    What is chronic kidney disease (CKD)?

    Kidneys a e as i o tant to you health as you hea t o you lungs. ha ed like kidney eans and a out the size oyou st you kidneys a e located on eithe side o you s ine unde the lowe i s. Thei ain task is to e ove waste

    oducts o you lood. You kidneys also oduce i o tant ho ones that egulate so e o you odys unctionsand hel alance wate and ine als in you ody. Ch onic kidney disease (CKD) e e s to a edical condition whe e you kidneys a ility to lte wastes o you odyis i ai ed. CKD usually sta ts slowly and og esses ove a nu e o yea s. I diagnosed and t eated ea ly CKD ay

    e slowed down o sto ed. Howeve i it kee s getting wo se CKD ay lead to kidney ailu e also called End- tageRenal Disease (E RD). I you have E RD t eat ent o tions include dialysis o a kidney t ans lant. These t eat entscan hel you stay healthy and continue you daily activities.

    The e is no cu e o CKD the goal o t eat ent is to kee the kidneys unctioning as long as ossi le y detectingand t eating the disease at its ea ly stages. o eti es i t eated ea ly all that ay e needed is a change in you dietcont ol o you lood essu e and/o so e s eci c edication.

    What are the symptoms o kidney disease? CKD is a silent disease. Most eo le do not have any sy to s in the ea ly stages. y to s egin when osto you kidney unction is lost. y to s that ay show u as you kidney unction dete io ates include equentheadaches atigue and itching all ove the ody.

    As kidney disease wo sens the ody is una le to get id o waste oducts and excess wate . This condition is calledu e ia. In addition to ea lie sy to s you ay ex e ience:

    F equent u ination o assing less u ine welling in legs ankles eet ace and/o hands Metallic o ad taste in outh Nausea and vo iting Loss o a etite

    Who is at risk o developing CKD?

    The leading causes o kidney ailu e a e diabetes and high blood pressure . These conditions inte e e with the lte ingThese conditions inte e e with the lte inga ility o the kidneys and can lead to kidney ailu e. Ea ly diagnosis and ca e ul anage ent o these conditions canEa ly diagnosis and ca e ul anage ent o these conditions candelay and even event the onset o kidney ailu e. Talk to you docto i you have dia etes o hy e tension. OtheTalk to you docto i you have dia etes o hy e tension. Othe

    acto s that inc ease a e sons isk o develo ing CKD include:

    Fa ily histo y o kidney disease (e.g. olycystic kidney disease) Ce tain ethnic g ou s (Fi st Nations Paci c Islande s) Ove use o anti-infa ato y d ugs and ain-kille s In ection o inju y to the kidneys (e.g. glo e ulone h itis)

    How can I prevent or control CKD?

    The e is no cu e o CKD ut y lea ning o e a out you illness and taking an active a t in anaging you healthyou ay e a le to kee you kidneys unctioning longe . Conside using the Chronic Kidney Disease Flow Sheet to

    onito you og ess. You can take this fow sheet with you when you visit you docto . Othe i o tant things youcan do include:

    Control diabetesI you have dia etes kee you lood glucose levels as close to no al as ossi le. Along with taking you

    edications as esc i ed kee you weight unde cont ol and exe cise egula ly. You docto should outinely testwhethe you kidneys a e unctioning o e ly.

    ho tness o eath Feeling cold T ou le concent ating dizziness Leg ain/ uscle c a s

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    Kidney Foundation o Canada (BC Branch)

    Tel: 6 4 736-977 (Vancouve a ea) 67- (elsewhe e in BC)

    Fax: 6 4 736-97 3E ail: in [email protected] c.ca

    The Kidney Foundation has atient su o t g ou s inany a eas o BC as well as educational ate ial and

    o e s sho t te nancial assistance o those in need.

    BC Provincial Renal Agency (BCPRA)

    Tel: 6 4 7 -734E ail: c [email protected] c a.u c.ca

    The BC P ovincial Renal Agency is a colla o ative o enal health o essionals who coo dinate the ca eo atients with kidney disease in BC.

    BC Health Guide

    In o ation on kidney disease can e ound in the BC HealthGuide Online at www. chealthguide.o g oin the BC HealthGuide Hand ook ovided ee to households th oughout the ovince. The 4-Hou BCHealthGuide Nu seLine uts you in touch with a Registe ed Nu se any ti e day o night just y calling one othe ollowing nu e s:

    Local calling within G eate Vancouve : 6 4 -47Toll- ee elsewhe e within BC: 66 -47Dea and hea ing-i ai ed toll- ee ovince wide: 66 TTY-47

    Control high blood pressure (hypertension) High lood essu e causes kidney da age and will also cause kidney unction to dete io ate o e quickly. Cont ol

    you high lood essu e to 3 / . Wo k with you docto to nd the anti-hy e tension edications that wo k esto you. Kee you weight unde cont ol exe cise egula ly and educe you salt intake to hel kee you lood

    essu e at a healthy level.

    Lead a smoke ree li eTo hel event kidney disease sto s oking and avoid ex osu e to second hand s oke.

    Eat wellI you have CKD it is i o tant to have a diet that eets you nut itional needs. Lea n how o e ood choicescan hel you. Talk to a nut itionist o dietit ian a out a ood lan that is ight o you. Be awa e that ce tain oods cancause kidney unction to dete io ate o e quickly. A diet that is too high in otein can cause o le s.

    Exercise and control your weightExe cising egula ly is one o the est things you can do to i ove you ove all health. Exe cise hel s you to loweyou lood suga and lood essu e achieve a healthy weight i ove you hea t and lung health and i oveyou hysical ental and e otional well eing.

    Do not overuse over-the-counter drugsP olonged and equent use o anti-infa ato y and anti- ain edications can da age you kidneys. Talk to youdocto o ha acist to nd out how to use non- esc i tion edication that wont da age you kidneys.

    Reduce stressRecognize that it ay take ti e to adjust to CKD so e atient and set ealistic goals. Kee involved in the

    leasu es activities and es onsi ilities o daily li e and sha e you eelings with a ily and close iends. Conside joining a su o t g ou .

    Resources or People with Chronic Kidney Disease

    The Living with Kidney Disease atient anualoduced y The Kidney Foundation o Canada is an

    i o tant educational e e ence o eo le living withkidney disease. The anual is availa le in English & F ench on the Kidney Foundation we site:

    www.kidney.ca/ u lications-eng.htIt is also availa le in English F ench Chinese ItalianPo tuguese & Punja i o the BC B anch.

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