Chronic Kidney Disease Management
Chronic illness has a profound effect on the physical, emotional and mental well-being of individuals, often making it difficult to carry on with daily routines and relationships. However, in many cases, deterioration in health can be minimized by good care. A patient's ability to follow medical advice, accommodate lifestyle changes, and access resources are all factors that influence successful management of an ongoing illness.
Chronic disease management (CDM) is an approach to health care that helps individuals maintain independence and keep as healthy as possible through prevention, early detection, and management of chronic conditions, such as kidney disease (as well as congestive heart failure, asthma, diabetes etc).
BCPRA is a partner in the development of a chronic kidney disease (CKD) management program.
This evidence-based initiative suggests progression of CKD can be slowed or even prevented through good management at the community level.
The initiative includes:
Kidney care programs across BC utilize various components and models of chronic disease management in the delivery of care to patients. BCPRA is providing support on a variety of levels to these initiatives, most notably through our clinical information system, PROMIS.
Lab Strategy for Early Diagnosis
If kidney disease can be identified early, it can be managed through diet and lifestyle adjustments that can delay the need for dialysis.
With this in mind, the British Columbia Provincial Renal Agency, Ministry of Health Services, the BC Medical Association and laboratory physicians launched an initiative to identify those at highest risk for kidney disease at an earlier stage.
Through the BC Chronic Kidney Disease Lab Strategy, BC laboratories are now reporting estimated glomerular filtration rates (GFR) in addition to serum creatinine. Labs automatically report the GFR results to general practitioners and other doctors who are not nephrologists.
Why GFR? The medical research literature suggests that the serum creatinine measurement does not provide an accurate measure of kidney function (Mitch, Collier & Walswer, 1980; Levin, 2002).
For example, a recent Canadian study (Duncan, Heathcote, Djurdjev & Levin, 2001) found that among patients 70 years and older, 47% had normal serum creatinine levels but abnormal glomerular filtration rates (12.5% among 60-69 yrs, and 1.2% among those 40-59 years of age).
The National Kidney Foundation’s Kidney Disease Outcome Quality Initiative (K/DOQI) recommended that clinical laboratories should provide an estimate of GFR with the results of serum creatinine concentration.
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Clinical Practice Guideline for Physicians
A BC clinical practice guideline – Identification, Evaluation and Management of Patients with Chronic Kidney Disease – has been developed through the MSP/BCMA Guidelines and Protocols Advisory Committee.
Based on the best scientific evidence currently available, this guideline dispels the common belief that very little can be done to slow or prevent the onset of end-stage renal disease.
The clinical guideline also includes patient flow sheets, which are valuable tools for summarizing the care patients have received, identifying any gaps in care, and for planning future patient visits. Also included is a guide for patients on managing their health and accessing community-based resources.
Physicians can easily access the guidelines, the patient flow sheets and a patient reminder and recall system through the CDM toolkit – an expansion of the Ministry of Health Service’s CDM Secure Website that interfaces with PDA technology. In addition, the CDM toolkit enables members of practice networks to securely share information (including consult notes and referral letters) needed to ensure continuity of patient care.
back to topPatient Self-Management SupportChronic illness has a profound effect on the physical, emotional and mental well-being of individuals, often making it difficult to carry on with daily routines and relationships. However, in many cases, deterioration in health can be minimized by good care.
People who have chronic kidney disease live with their condition twenty-four hours a day. They need to make daily decisions and take action to control pain and fatigue, use medications properly, and incorporate diet, exercise and stress reduction into their daily routines.
A valuable resource available to help empower people to become experts in managing their health is the
BC Ministry of Health Services Chronic Disease Management website.
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