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 □ |