1 must be met and either 2 or 3 or 4 must be met

1. Dialysis/Renal Transplant Status (a or b must be met)
a. No Dialysis (i and ii must be met)

i. Has patient been ruled out as a candidate for renal transplant?
ii. Is patient either not seeking dialysis or is discontinuing dialysis?

OR

b. With Dialysis (i, ii, and iii must be met)
i. Is patient currently on dialysis?
ii. Is dialysis for patient comfort only?
iii. Patient's prognosis remains unaltered even with dialysis?

AND

2. Creatinine Clearance (a or b must be met)
a. Is creatinine clearance < 10 cc/min (<15 cc/min for diabetics)?
b. Is creatinine clearance < 15 cc/min (<20 cc/min for diabetics)?

OR

3. Serum Creatinine
Is serum creatinine > 8.0 mg/dl (>6.0 mg/dl for diabeteics)?

OR
4. Estimated Glomerular Filtration (GFR)
Is GFR rate < 10 ml/min?

5) Co-morbid Condition - Supporting Factor

  • Mechanical ventilation
  • Autoimmune Disease
  • Digestive Disease
  • Heart Disease
  • Liver Disease
  • Pulmonary Disease