Table 1 Questionnaire in patients with chronic kidney disease (CKD)
INDIVIDUAL PATIENT DATA | Date ____/____/________ | ||||
|---|---|---|---|---|---|
Centre: | Identification number: | ||||
Sex: | men □ | women □ | Age: | ||
Visit: | VO V1 V2 V3 V4 | CKD stage: | 2 3 4 5 | ||
Glomerular Filtration Rate (CKD-EPI): | CKD etiology: | ||||
DIALYSIS : | Yes □ | No □ | Modality: HD □ | PD □ | Time on dialysis (months): |
HEMODIALYSIS (HD): | membrane type: | low flux □ | high flux □ | ||
Frequency HD: | 3 d/week □ | /48 h □ | /24 h □ | Duration HD (hours): | |
KtV (last measured value): | |||||
Type of HD access: | arteriovenous shunt □ | graft □ | catheter □ | ||
PERITONEAL DIALYSIS (PD): | Type: | Automatic □ | Manual □ | ||
Transport type: | low □ | high □ | Icodextrin administration: | Yes □ | No □ |
Total infused volume (ml): | Total eliminated volume (ml): | ||||
diuresis volume (ml): | residual renal function (ml/min): | ||||
Total KtV (last measured value): | peritoneal ktV (last measured value): | ||||
Peritonitis (last year): | Yes □ | No □ | number of peritonitis: | ||
COMORBIDITIES | |||||
Diabetes: | Yes □ | No □ | |||
Hypertension: | Yes □ | No □ | |||
Heart failure: | Yes □ | No □ | |||
Atrial fibrillation: | Yes □ | No □ | |||
Dyslipidemia: | Yes □ | No □ | |||
Family history of early cardiovascular disease: | Yes □ | No □ | |||
Parathyroidectomy: | Yes □ | No □ | |||
LABORATORY DATA | Date ____/____/________ | ||||
Hemoglobin (g/dl): | Urea (mg/dl): | ||||
Hematocrit (%): | Uric acid (mg/dl): | ||||
Iron (mg/dl): | Glucose (mg/dl): | ||||
Transferrin (mg/dl): | HbA1c (%): | ||||
Ferritin (ng/ml): | Insulin (U/l): | ||||
Total calcium (mg/dl): | Cystatin C (mg/l): | ||||
Phosphorus (mg/dl): | Total cholesterol (mg/dl): | ||||
Intact parathormone level (pg/mL): | Triglycerides (mg/dl): | ||||
Sodium (mEq/L): | HDL cholesterol (mg/dl): | ||||
Potassium (mEq/L): | LDL cholesterol (mg/dl): | ||||
Albumin (g/dl): | Hepatitis C virus positive: | Yes □ | No □ | ||
Creatinin (mg/dl): | Microalbuminuria (mg/l) (urine): | ||||
AST/ALT (U/L): | Albumin/creatinin (mg/g) (urine): | ||||
MEDICAL TREATMENT | Platelet inhibitors: | Yes □ | No □ | ||
Antihypertensives: | Yes □ | No □ | Oral anticoagulants: | Yes □ | No □ |
Length of treatment (months): | Phosphate binders: | CO3Ca □ | sevelamer □ | ||
Angiotensio-converting enzyme (ACE) | calcium acetate □ | Al(OH)3 □ | lanthane □ | ||
inhibitors: | Yes □ | No □ | Total dose (g/day): | ||
Angiotensin II | receptor | blockers | Lenght of treatment (months): | ||
(ARB): | Yes □ | No □ | Vitamin D analogues/metabolites: | Yes □ | No □ |
Hypolipidemics: | statins □ | fibrates □ | Type: | ||
Length of treatment (months): | Total dose (mcg/week): | ||||
Insulin: | Yes □ | No □ | Length of treatment (months): | ||
Oral antidiabetics: | Yes □ | No □ | Erythropoiesis-stimulating agents: | Yes □ | No □ |