Important Updates in the Early
Detection & Management of
Chronic Kidney Disease
General Practitioner Workshop
This workshop was conceived and developed by the Kidney Check Australia Taskforce
with particular thanks to A/Prof Robyn Langham & A/Prof Timothy Mathew
2013
Learning Objectives
List the eight major risk factors for developing
chronic kidney disease (CKD)
Explain and apply the changes in recommendations for the
detection and staging of CKD focusing primarily on early
detection and management
Summarise the treatment options to delay progression
of kidney disease
Outline the importance of developing a system to identify
patients at higher risk of CKD for a Kidney Health Check
What is CKD?
Chronic kidney disease is defined as:
Glomerular Filtration Rate (GFR) < 60 mL/min/1.73m2 for ≥3 months with or
without evidence of kidney damage.
OR
Evidence of kidney damage (with or without decreased GFR) for ≥3 months:
•
•
•
•
albuminuria
haematuria after exclusion of urological causes
pathological abnormalities
anatomical abnormalities.
CKD is a major public health problem
• 1 in 9 Australian adults has CKD
• You can lose up to 90% of your kidney function before
experiencing any symptoms
• Major risk factor for cardiovascular disease
• Usual setting for initial assessment and diagnosis is in
general practice
• Common, harmful & treatable
What is the role of the GP?
• early detection and management
of CKD
• management of early CKD
without referral to specialist
• assessing and modifying
cardiovascular risk factors
• treatment to slow or prevent
progression of kidney failure
• avoiding nephrotoxic drugs
Kidney disease in Australia
Australians aged ≥ 25 years
CKD staging is according to the
CKD-EPI equation
Stage 5 CKD
19,000
40,000
827,000
856,000
5 MILLION AT RISK
Stage 4 CKD
Stage 3 CKD
Stage 1 – 2 CKD
Hypertension
Diabetes
AusDiab Report, 2001; White et al 2010; Jun 10 ABS data; 2011 ANZDATA report
Growth in incidence rate of new treated
ESKD and projections to 2020
AIHW, 2011. Projections of the incidence of treated End-Stage Kidney Disease in Australia, 2010-2020
Costs of treating current and new ESKD
cases to 2020
$13,000
$12,000
Cumulative Cost ($millions)
$11,000
$10,000
In 2009 dollars the cumulative cost of RRT
between $11.3 billion and $12.3 billion by the
end of 2020
$9,000
$8,000
$7,000
$6,000
$5,000
$4,000
Annual cost of RRT service provision
between $1.58 billion and $1.86 in 2020
dollars
$3,000
$2,000
$1,000
$0
2009
2010
2011
2012
2013
2014
Cumulative present value costs, Model 1
2015
2016
2017
2018
2019
2020
Cumulative present value costs, Model 2
Cass et al, 2010, economic impact ESKD in Australia, KHA
Number of treated or non-treated cases by
age group at ESKD onset 2003-2007
No dialysis / transplant
dialysis / transplant
Source: Linked ANZDATA Registry, AIHW National Mortality Database and National Death Index
What’s new in CKD?
 New CKD staging
 New recommendations for testing for urine protein
 New recommendations for eGFR and elderly
people with CKD
 New blood pressure targets
The new CKD staging system for Australia
2012 sees the introduction of a new CKD
staging system because it:
 Had a better correlation with progression
 Factored in albuminuria
 Resulted in quantification of risk for
• CKD progression
• CV events
What’s new in CKD?
Staging of Chronic Kidney Disease
Old
New
Rationale
CKD staging Determined by Determined by kidney function Recommended by all
system
eGFR
(eGFR) and the level of
Australian and
albuminuria in all stages of CKD international guidelines
and is a better
indicator of overall risk
Stage 3 CKD Stage 3 CKD
(eGFR 30-59
mL/min/1.73m2)
Divided into
Stage 3a (eGFR 45-59
mL/min/1.73m2)
Stage 3b (eGFR 30-44
mL/min/1.73m2)
More accurately
reflects risk
stratification
Risk of ESKD related to baseline proteinuria
(dipstick) over 18 year period
N= 106,000
Iseki et al, Kidney Int 2003;63:1468-1476
Blue – normal ACR
Green – microalbuminuria
Red - macroalbuminuria
Note log scale on Y axis for Hazard Ratio
Adapted from Levey et al, 2010, Kidney International
The new Australian CKD staging schema
Albuminuria Stage
GFR
Stage
(mL/min/1.73m2)
1
≥90
2
60-89
3a
45-59
3b
30-44
4
15-29
5
<15 or on dialysis
GFR
Normal
(urine ACR mg/mmol)
Male: < 2.5
Female: < 3.5
Not CKD unless
haematuria, structural or
pathological
abnormalities present
Microalbuminuria
(urine ACR mg/mmol)
Male: 2.5-25
Female: 3.5-35
Macroalbuminuria
(urine ACR mg/mmol)
Male: > 25
Female: > 35
Using the new CKD staging schema
‘CKD Management in General Practice’ booklet
has colour-coded action plans for overall risk of
• Progression of CKD
• Cardiovascular events
Normal
Low
Moderate
High
The new CKD staging system for Australia
CKD Stages are described by both
• eGFR & Albuminuria status
• Underlying cause of CKD
e.g Mrs S is a 55 year old lady with CKD 3b
with microalbuminuria secondary to
type 2 Diabetes
People at increased risk of CKD
Eight major risk factors for CKD
Diabetes
High blood pressure
Age over 60 years
Smoking
Obesity
Family history of kidney disease
Aboriginal or Torres Strait Islander origin
Established cardiovascular disease
1 in 3 Australian adults is at increased risk of CKD
due to the above risk factors!
How do we detect CKD?
New Recommendations for CKD detection
Test Kidney Function
Blood test for eGFR (creatinine)
Test for Albuminuria
Urine test for albumin / creatinine ratio (ACR)
Test for Hypertension
Check patient’s blood pressure
Remember…
Kidney Health Check
Blood
Test
Urine Test
BP Check
CKD screening should be undertaken as a part of a
systematic chronic disease assessment
What is GFR?
GFR = Glomerular Filtration Rate
•
GFR is accepted as the best measure of kidney function
•
May fall substantially before serum creatinine is outside the
normal range
•
Normal GFR in healthy adults is >90mL/min/1.73m2 and
declines with age
•
A GFR consistently <60mL/min/1.73m2 indicates CKD
•
A GFR of 60-90mL/min/1.73m2 should not be considered abnormal unless there
is evidence of kidney damage.
•
A fall in GFR always precedes kidney failure
•
There is no direct way of measuring GFR
•
GFR can be estimated from serum creatinine using prediction equations
•
The eGFR is reported by all Australian pathology labs
How will eGFR help me and my patients?
Early detection & management of CKD:
• slows progression
• prevents complications
• reduces cardiovascular risk
• reduces morbidity & mortality
Early detection and treatment may reduce the rate
of progression of kidney failure and cardiovascular
risk by 20 – 50%
What’s new in CKD?
eGFR – estimated Glomerular Filtration Rate
What
Old
New
Rationale
eGFR &
elderly
If aged >70 years, stable
eGFR between 45-59
mL/min/1.73m2 may be
ok for age in some cases
Age-related
decision points
are not
recommended
eGFR<60 mL/min/1.73m2 is
associated with significantly
increased risks of adverse clinical
outcomes irrespective of age
It is now recommended that the CKD-EPI formula is used to calculate
eGFR instead of the previously used MDRD formula
This will lead to improved risk stratification and will make little or no
difference to your practice
What is eGFR?
Since 2005 it has been recommended that eGFR
be automatically reported with every request for serum
creatinine in adults.
This is consistent with USA, UK & Australian clinical guidelines
CKD-EPI formula is now recommended because:
Thoroughly validated equation in adults
Superior to other equations and to 24-hour urine collections
(when GFR <60 mL/min/1.73m2)
No requirement for additional measurements of BSA
See calculator at http://www.kidney.org.au
Advantages of eGFR
 eGFR is a more sensitive marker for mild/moderate CKD than
creatinine alone
 Serum creatinine concentration is an insensitive marker for
detecting mild to moderate kidney failure
 Patients may lose 50% or more of their kidney function before
the serum creatinine rises above the upper limit of normal
 Normal serum creatinine measurements do not exclude
serious loss of kidney function
Comparing eGFR and creatinine
CKD 1&2
Serum
creatinine
CKD 3
120
90
60
GFR mL/min
CKD 4 CKD 5
30
Normal Serum Creatinine Level
Actual Serum Creatinine Level
0
Limitations of eGFR
Clinical situations where eGFR results may be unreliable and/or
misleading:
• acute changes in kidney function
• people on dialysis
• exceptional dietary intake (e.g. vegetarian diet, high protein diet, recent
consumption of cooked meat, creatine supplements)
• extremes of body size
• diseases of skeletal muscle, paraplegia or amputees (may overestimate
eGFR) or high muscle mass (may underestimate eGFR)
• children under the age of 18 years
• severe liver disease present
• eGFR values above 90 mL/min/1.73m2
• drugs interacting with creatinine excretion (eg fenofibrate,
trimethoprim)
eGFR and drug dosing
• Where an eGFR (using CKD-EPI or MDRD) is on hand it is clinically
appropriate to use this to assist drug dosing decision making
Recommendation:
• Dose reduction of some drugs is recommended for patients with
reduced kidney function
• Both eGFR (mL/min/1.73m2) and estimated CrCl (mL/min) provide an
estimate of relative renal drug clearance
• If using eGFR for drug dosing body size should be considered, in
addition to referring to the approved Product Information
• For drugs with a narrow therapeutic index, therapeutic drug
monitoring or a valid marker of drug effect should be used to
individualise dosing
Remember…
Kidney Health Check
Blood
Test
Urine Test
BP Check
CKD screening should be undertaken as a part of a
systematic chronic disease assessment
What’s new in CKD?
Urine Tests for proteinuria
What
Old
New
Urine testing for
proteinuria
Non-diabetes
? dipstick
? 24 hr urine protein
? PCR
? ACR
Diabetes
ACR recommended
Urine Albumin/ Creatinine ratio (ACR)
recommended for everyone
Clinical Tip
The preferred method for assessment of albuminuria in both diabetes and nondiabetes is urinary ACR measurement in a first void spot specimen
Where a first void specimen is not possible or practical, a random spot urine
specimen for urine ACR is acceptable
Urine Albumin / Creatinine Ratio (ACR)
• Exhibits greater sensitivity than protein:creatinine ratio (PCR)
• An initial ACR test should be repeated on a first void sample
• Albuminuria is present if at least two out of three ACR tests
are positive (including the initial test). CKD is present if the
albuminuria is persistent for at least three months
• Dipsticks for protein in the urine are now no longer
recommended for this purpose as their sensitivity and
specificity is not optimal
Albuminuria
• There is an association between albuminuria and
progressive kidney disease in population studies
• The severity of albuminuria is predictive of outcome
• Therapeutic intervention can delay progression of
disease and is most effective where there is significant
albuminuria
• Microalbuminuria is predictive of progressive renal
disease in people with diabetes and Indigenous people.
• Urine ACR accurately predicts renal and cardiovascular
risks in population studies and reduction in urine ACR
predicts renoprotective benefit in intervention trials
Approximate equivalents between urine
ACR & other measure of albumin & protein
Kidney Health Check
Blood
Test
Urine Test
BP Check
CKD screening should be undertaken as a part of a
systematic chronic disease assessment
What’s new in CKD?
Blood Pressure Targets
What
Old
New
Blood Pressure
Targets
People with >1g proteinuria/ day
– BP target 125/75 mmHg
People with CKD - should
maintain a BP consistently
below 140/90 mmHg
People with CKD (or other
conditions) – BP target 130/80
mmHg
All other conditions – BP target
140/90 mmHg
People with diabetes or
microalbuminuria should
maintain a BP consistently
below 130/80 mmHg
Case study
Rita
Rita is a new patient to your practice
• 63 years old
• Accountant
• History of mild asthma
Case study - Rita
Past medical history
• Overweight (BMI 29)
• Mild intermittent asthma
• Chronic low back pain
• Mild hypertension
• Smoker 25 pack year history
Family history
• Maternal grandmother died of a heart attack in her
60’s but also had a history of ‘kidney problems’
• Mother has type 2 diabetes
• Father has angina and hypertension
Case study - Rita
Smoker:
20-25 cigarettes per day
Alcohol:
1-2 glasses of wine
3-4 nights per week
Allergies:
Nil known
Salbutamol 100mcg/dose
Medications:
as needed
Case study - Question
Groups at increased risk of CKD
Risk factors for CKD
High blood pressure
Smoking
Age over 60 years
Family history of kidney disease
Diabetes
 Obesity
Aboriginal or Torres Strait Islander origin
Established cardiovascular disease
Rita has 4 of the 8 Risk Factors
CKD risk factors: Diabetes
• Patients who have diabetes develop CKD in
up to 25% of cases.
• 1% of adult Australians develop diabetes
each year (Barr et al. 2006, Int. Diab Institute)
CKD risk factors: Obesity
Being overweight (BMI 25-29 kg/m2 did not
increase CKD risk, but all classes of obesity (BMI ≥
30kg/m2) increased risk
*CKD with eGFR <45mL/min/1.73m2
Hallan et al, Am J Kid Dis 2006
Relative Risk of CKD* (95% CI)
CKD risk factor: Smoking
Smokers with a 25-49 pack-year history had an increased
risk of 42% compared with non-smokers and those with
>50 pack years had 105% increased risk
*CKD with eGFR <45mL/min/1.73m2
Hallan et al, Am J Kid Dis 2006
CKD risk factors: High blood pressure
High Blood pressure can damage the small blood vessels in the
kidneys. The damaged vessels cannot filter waste products from
the blood the way they should.
Parenchymal Renal
Disease
Hypertension
Or……damaged kidneys cause high blood pressure and high
blood pressure damages kidneys
CKD risk factors: Age > 60 Years
Relationship of eGFR to age
160
eGFR (mL/min/1.73m2)
140
120
100
80
60
40
2.50%
Median
97.50%
20
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
80-84
85-90
90+
Age (years)
Australasian Creatinine Consensus group. MJA 2007; 187(8): 459-463
CKD risk factors: Family history
22.9
23.9
Family history (%) of ESKD in
incident dialysis patients
20
14.4
14.6
10
Caucasian
men
Caucasian
women
AfricanAmerican
men
AfricanAmerican
women
Freedman et al., JASN 1997
CKD risk factors: Aboriginal or Torres Strait
Islander Origin
Indigenous Australians
starting treatment for ESKD
Age group (years)
Australian Institute of Health and Welfare, 2011
Case study - Answer
Rita has 4 risk factors for CKD
• Smoking
• Age over 60
• Family history
• High blood pressure
Case study - Question
Who should be tested for kidney disease?
Risk Factor
Recommended Tests
Frequency
Urine ACR
eGFR
Blood Pressure
Every 1-2 years*
Smoker
Diabetes
Hypertension
Obesity
Established cardiovascular disease
Family history of CKD
Aboriginal or Torres Strait Islander
origin aged over 30 years
*yearly for people with diabetes or hypertension
If an individual has multiple risk factors, follow the more
frequent regime
Case study - Rita
You determine that Rita should have a kidney health check
every year
Kidney Health Check
Blood Test
Creatinine & eGFR
Urine Test
Albumin / Creatinine
Ratio (ACR) to check
for albuminuria
BP Check
Blood pressure
should be
consistently below
140/90 mmHg
If all 3 tests are normal then the kidneys are in good shape and need
only be tested again as indicated by the applicable risk factors
Case study - Rita
Rita’s Kidney Health Check Results
Creatinine
118 µmol/L
eGFR
55 mL/min/1.73m2
Urine ACR
5.7 mg/mmol
Blood Pressure
155 / 95 mmHg
Case study - Rita
Albuminuria Stage
GFR Stage
GFR
(mL/min/1.
73m2)
Normal
(urine ACR
mg/mmol)
Male: < 2.5
Female: < 3.5
1
≥90
2
60-89
Not CKD unless
haematuria,
structural or
pathological
abnormalities present
3a
45-59
Microalbuminuria Macroalbuminuria
(urine ACR
(urine ACR
mg/mmol)
mg/mmol)
Male: 2.5-25
Male: > 25
Female: 3.5-35
Female: > 35
RITA’S RESULTS
PUT HER HERE
3b
30-44
4
15-29
5
<15 or on
dialysis
Case study - Question
Not yet!
Case study - Rita
To classify Rita as having CKD, her urine ACR &
eGFR will need to be repeated
• If the first ACR is a random spot, then repeat tests should
ideally be first morning void specimens
• CKD is present if at least 2 out of 3 ACR tests (including the
initial test) in the next three months are positive
• When initial eGFR is <60 mL/min/1.73m2 consider clinical
situations where eGFR results may be unreliable/misleading
• To confirm CKD, the repeat eGFR in 3 months time should
also be below 60mL/min/1.73m2
Repeating the urine ACR
Factors other than CKD know to increase urine
albumin excretion…
 Urinary Tract Infection
 High dietary protein intake
 Congestive cardiac failure
 Acute febrile illness
 Heavy exercise within 24 hours
 Menstruation or vaginal discharge
 Drugs (especially NSAIDs)
Case study - Question
Rita comes back to see you three months
later and you repeat her urine ACR, eGFR
and blood pressure…
Test
1st Visit
eGFR
55 mL/min/1.73m2
Urine ACR 5.7 mg/mmol
BP
155/95 mmHg
This Visit
52 mL/min/1.73m2
8.4 mg/mmol
160/95 mmHg
Case study - Rita
You can now diagnose Rita as having CKD stage
3a with microalbuminuria
Albuminuria Stage
GFR Stage
GFR
(mL/min/1.73m2)
1
≥90
2
60-89
3a
45-59
3b
30-44
4
15-29
5
<15 or on dialysis
Normal
(urine ACR mg/mmol)
Male: < 2.5
Female: < 3.5
Microalbuminuria
(urine ACR mg/mmol)
Male: 2.5-25
Female: 3.5-35
Not CKD unless
haematuria, structural or
pathological
abnormalities present
RITA FITS HERE
Macroalbuminuria
(urine ACR mg/mmol)
Male: > 25
Female: > 35
Case study - Rita
Orange Clinical Action Plan
eGFR 30-59 mL/min/1.73m2 with microalbuminuria or eGFR 30-44 with normoalbuminuria
Goals of Management
•
•
•
•
•
Investigations to exclude treatable disease
Reduce progression of disease
Reduce cardiovascular risk
Early detection & management of complications
Avoidance of nephrotoxic medications or volume
depletion
• Adjustment of medication doses to levels appropriate for
kidney function
• Appropriate referral to a Nephrologist
Case study - Rita
Orange Clinical Action Plan
eGFR 30-59 mL/min/1.73m2 with microalbuminuria or eGFR 30-44 with normoalbuminuria
Monitoring
 3-6 monthly clinical review
Blood pressure
Clinical
assessment Weight
Urine ACR
Biochemical profile including urea, creatinine,
electrolytes
Laboratory eGFR
assessment HbA1c (for people with diabetes)
Fasting lipids
Full blood count
Calcium and phosphate
Parathyroid hormone (6-12 monthly if eGFR <45
mL/min/1.73m2)
Case study - Rita
Orange Clinical Action Plan
eGFR 30-59 mL/min/1.73m2 with microalbuminuria or eGFR 30-44 with normoalbuminuria
It is also important to consider…
•
•
•
•
•
Absolute Cardiovascular Risk assessment
Lifestyle modification
Blood pressure reduction
Lipid lowering treatments
Glycaemic control
Case study - Question
Cardiovascular risk reduction
• Individuals with CKD have a 2-3 fold greater risk of cardiac
death than individuals without CKD
• People with CKD are at least 20 times more likely to die from
cardiovascular disease than survive to need dialysis or
transplant
• CKD is one of the most potent known risk factors for
cardiovascular disease
• It is important to calculate Rita’s cardiovascular risk using the
Australian cardiovascular risk tool at www.cvdcheck.org.au
Australian Cardiovascular Risk Tool
Rita’s Cardiovascular Risk (www.cvdcheck.org.au)
• The tool is approved by NH&MRC
• If Rita had moderate to severe CKD defined as eGFR <45
mL/min/1.73m2 or macroalbuminuria (ACR >25mg/mmol men;
>35mg/mmol women) she would be at the highest CVD risk and in
this case the tool should not be applied
Blood pressure reduction
• CKD can cause and aggravate hypertension and hypertension
can contribute to the progression of CKD
• Reducing blood pressure to below target levels is one of the
most important goals of CKD management
• ACE inhibitor or ARB is recommended first line therapy
• Combined therapy of ACE & ARB is not recommended
• Maximal tolerated doses of ACE inhibitor or ARB is
recommended
• Hypertension may be difficult to control and multiple (3-4)
medications are frequently required
Rita has stage 3a CKD with microalbuminuria so her blood pressure
needs to be maintained consistently below 130/80 mmHg
Blood pressure reduction
Clinical Tips
• ACE inhibitors and ARBs can cause a reversible
reduction in GFR when treatment initiated
• If the reduction is less than 25% and stabilises within
two months of starting therapy, the ACE inhibitor or
ARB should be continued
• If the reduction in GFR exceeds 25% below the
baseline value, the ACE inhibitor or ARB should be
ceased and consideration given to referral to a
Nephrologist for bilateral renal artery stenosis
Adequate BP management delays the
progression of CKD
160/95
If Rita’s blood pressure was consistently
below target, the GFR loss per year would be
reduced by 80%
Bakris et al., Am J Kid Disease, 2000
Lifestyle modification
Lifestyle approaches are essential in
reducing the overall cardiovascular risk the key elements are:
‘SNAP’ (smoking, nutrition, alcohol,
physical activity)
 Stop smoking
 A low calorie diet to reduce BMI
 A low salt diet
 Weight reduction
 A reduction in alcohol intake
 Physical activity
Lifestyle modification effects on BP
Modification
Recommendation
Approx SBP reduction
Weight reduction
BMI 18-24.9 kg/m2
5-20 mmHg / 10kg lost
Dietary salt restriction <100 mmol/day
2-8 mmHg
DASH* diet
Fruit, vegies, low saturated
and total fat
8-14 mmHg
Physical activity
Aerobic activity for 30mins
most days
4-9 mmHg
Moderate alcohol
consumption only
1-2 standard drinks/day
2-4 mmHg
* Dietary Approaches to Stop Hypertension
Lipid lowering & glycaemic control
Lipids
• Margaret’s lipids should be assessed
• Lipid-lowering treatment should be
considered for CVD risk reduction
Glycaemic control
• Margaret’s glycaemic control should be
assessed
• For people with diabetes, blood glucose
control significantly reduces the risk of
developing CKD, and in those with CKD
reduces the rate of progression
Case study - Question
Referral to a Nephrologist is recommended if:
• eGFR <30mL/min/1.73m2
• Persistent significant albuminuria (urine ACR ≥ 30mg/mmol)
• Rapidly declining eGFR from a baseline of <60 mL/min/1.73m2
(a decline of >5mL/min/1.73m2 over a six-month period which is confirmed
on at least three separate readings)
• CKD and hypertension that is hard to get to target despite at least three
anti-hypertensive agents
• glomerular haematuria with macroalbuminuria
Anyone with an acute presentation and signs of acute nephritis (oliguria,
haematuria, acute hypertension, and oedema) should be regarded as a
medical emergency and referred without delay
Clinical tip
When referring to a Nephrologist ensure patient has had a recent urine ACR,
current blood chemistry and haematology and a urinary tract ultrasound.
Referral is NOT usually necessary if:
• Stable eGFR ≥30 mL/min/1.73m2
• Urine ACR < 30mg/mmol (with no haematuria)
• Controlled blood pressure
The decision to refer or not must always be individualised and particularly in
younger patients the indications for referral may be less stringent.
Useful Tips
 Pay attention to CVD risk reduction
 Consider discussing management issues with a Nephrologist in
cases where uncertainty regarding referral exists.
 Don’t refer to Nephrologist if targets of therapy are achieved
 Spiral CT angiogram for hypertension is not recommended
without specialty advice
Case study – Action plan
Orange Clinical Action Plan
eGFR 30-59 mL/min/1.73m2 with microalbuminuria or eGFR 30-44 with normoalbuminuria
• Follow the ‘Orange’ clinical action plan (found in ‘CKD
management in General Practice’ 2nd ed)
• Cardiovascular risk reduction
• Blood Pressure should be consistently below 130/80
mmHg – use of ACE or ARB as appropriate
• Lifestyle modification
• Avoid nephrotoxic medications
• Adjust dose of other medications to levels appropriate
for her kidney function
• No need for Nephrology referral at this stage
• Continue to monitor 3-6 monthly
Treatment target for people with CKD
Parameter
Target
Blood Pressure
≤ 140/90 mmHg or
≤ 130/80 mmHg if albuminuria is present
(ACR > 2.5 mg/mmol males; >3.5 mg/mmol females)
Treatment
Lifestyle modification
ACE inhibitor or ARB
Albuminuria
>50% reduction of baseline value
ACE inhibitor or ARB
Cholesterol
Total < 4.0 mmol/L
LDL < 2.5 mmol/L
Dietary advice
statins
Blood glucose
(for people with HbA1c <7.0% / 53 mmol/mol
diabetes)
Lifestyle modification
Oral hypoglycaemic
Insulin
Case study - Question
CKD diagnosis, management & patient
outcomes
The diagnosis of CKD brings with it the need to identify
risk reduction measures both for kidney and
cardiovascular diseases
• Treatment targets and choices of therapy may differ with a CKD
diagnosis
• Early detection and management of CKD complications
• Greater consideration of any prescribing - avoidance of nephrotoxic
medications and ensuring dosages of other prescribed drugs are
appropriate for the level of kidney function
• Timely referral of CKD patients to a Nephrologist for more severe
CKD or complications
Summary…
• CKD is common, harmful and treatable
• Early detection is beneficial
• Systematically identify patients at high risk of CKD (the 8 risk factors)
• Perform a Kidney Health Check (urine ACR, eGFR, blood pressure) on
at risk patients
• CKD is present if 2 /3 urine ACR tests in 3 month period are positive
• Repeat the eGFR if <60mL/min/1.73m2
• Maintain blood pressure consistently below the relevant threshold
• Refer to the CKD staging table and clinical action plans in ‘CKD
Management in General Practice (2nd ed)’
• GPs play a vital role in the management of CKD
• Most CKD patients can be managed in general practice
Remember…
New CKD staging
New recommendations for testing for
urine protein
New recommendations for eGFR and
elderly people with CKD
New blood pressure targets
Further resources…
CKD Management in
General Practice
2012 Guidelines booklet
New Edition!
now available at
www.kcat.org.au
Kidney Health Information Service
• Free call information service for people living
with / affected by kidney disease
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KHA allowing you to access:
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Information and invitations to KHA's education and support activities
Updates on medical research in kidney disease
Updates on clinical trials and research opportunities
Information on advocacy opportunities and government relations issues
Information on community and corporate events held by Kidney Health
Australia
To join the kidney community, email
community@kidney.org.au
Use of eGFR in different ethnic populations recommendations
• The CKD-EPI formula is a useful tool to estimate GFR in all
people, including various ethnic populations
• The CKD-EPI formula has been validated as a tool to estimate
GFR in some non-Caucasian populations, including South-East
Asian, African, Indian and Chinese individuals living in Western
countries
• The different methods to estimate GFR from serum creatinine
concentration have not been validated in Indigenous
Australians, although these studies are currently underway
Australasian Creatinine Consensus statement, 2012
Urine tests
Albuminuria or Proteinuria? That is the
question!!
• The term albuminuria includes increased urinary excretion of albumin
and increased urinary excretion of other proteins
• It is very rare for a patient to have increased excretion of non-albumin
proteins without concomitant increased excretion of albumin
• Excessive amounts of proteins in the urine are a key marker of kidney
damage and of increased renal and cardiovascular disease risk
• These proteins are mainly albumin (albuminuria), but also consist of
low molecular weight immunoglobulin, lysozyme, insulin and beta-2
microglobulin
Australasian Proteinuria Consensus statement, 2012