Chronic Kidney Disease &
Diabetes
for Primary Care Nurses
Primary Care Nurse Workshop
This workshop was conceived and developed by the Kidney Check Australia Taskforce
sub-committee for education in nursing in general practice, with particular thanks to the
KCAT team.
Version 04.14
KCAT Supporters
The KCAT program is proudly supported by unrestricted educational grants from:
KCAT Program Partners
KCAT Major Sponsor
Learning Outcomes
At the end of this workshop participants will:
Know the eight major risk factors for Chronic Kidney Disease (CKD)
Know how to measure kidney function and interpret the results
Understand the adjustments to treatment targets and management of
CKD in patients with diabetes
Understand the signs of diabetic kidney disease and what role the
practice nurse plays in its management
Develop confidence to include CKD testing and management into the
diabetes cycle of care
3
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.
Kidney Disease in Australia
Australians aged ≥ 18 years
Dialysis or transplant
19,000
Less than
10% of these
people are
aware they
have CKD
53,000
Stage 4-5 CKD
580,000
1,124,000
5+ MILLION AT RISK
Stage 3 CKD
Stage 1 – 2 CKD
Hypertension /
Diabetes
Australian Health Survey 2013; ABS population estimates June 2012
CKD staging is according to the CKD-EPI equation
The Australian CKD staging schema
X
Combine eGFR stage, albuminuria stage and
underlying diagnosis to specify CKD stage
(e.g., stage 3b CKD with microalbuminuria secondary to diabetic kidney disease)
Colour-coded Clinical Action Plans
Diabetic Kidney Disease (DKD)
• When damage to the kidneys is caused by diabetes it is
called Diabetic Kidney Disease (DKD) or diabetic
nephropathy.
• DKD can worsen other diabetic complications such as nerve
and eye damage
• DKD increases the risk of cardiovascular disease
• It usually has no symptoms until it is well advanced
Diabetic Kidney Disease (DKD)
• DKD is the most frequent cause of kidney failure worldwide
• DKD is associated with increased morbidity and mortality at all
stages of CKD
• Early detection and comprehensive management of DKD is
associated with improved outcomes
• CKD best care overlaps fully with cardiovascular risk reduction
and best diabetes care
CKD and diabetes
Every second patient you see with
Type 2 diabetes will have CKD (47%)*
A patient with diabetes has CKD if they have:
 Persistent microalbuminuria or proteinuria
 An eGFR < 60mL/min/1.73m2 and/or
 Haematuria after exclusion of urological causes or
structural abnormalities
*NEFRON Study 2007
The increasing burden of CKD and diabetes
Australia - 1981 to 2009
Number of new patients with ESKD due to diabetes starting on dialysis
900
800
700
600
500
400
300
200
100
0
Type2
Type 1
Diabetes is the cause of kidney failure that is largely
driving the increase in dialysis patients in Australia
45
Diabetes
Gn
BP
40
Misc
Uncertain
PCK
35
Reflux
Analg Nx
Rate pmp
30
25
20
15
10
5
0
1998
2000
2002
2004
2006
2008
ANZDATA Registry
Less than 1 in every 20 patients with diabetes and
CKD will live long enough to require dialysis or
transplantation*
Finding an eGFR < 60 really means:
 High risk of heart attack or stroke
 Less likely to survive a heart attack
 More likely to be hospitalised in next 12 months
 Likely to have heart failure
 Wounds will heal more slowly
 Ankle swelling and fluid retention are more difficult to control
 BP targets more difficult to achieve
 Higher likelihood of fractures with a fall
 Adverse drug reactions more common
 While blood sugar levels easier to control – more likely to have a hypo
*NEFRON Study 2007
Case Study
Larry
Case study - Larry
Background
• Larry is a 62 year old male of Caucasian
background
• He works full-time as a clerk in the Public Service
• Larry presents at your general practice with an
acute cough with yellow sputum
• He has previously been seen at your practice
when he accompanied his wife for an annual flu
vaccination
Case study - Larry
Larry’s History
• Larry has Type 2 diabetes that was diagnosed elsewhere a year ago
after he presented with thirst
• Smoking - 40 pack years (1 pack per day for 40 years)
• Alcohol - consumes 7-10 drinks per week
• Follows a “diabetic diet”
• Is on no regular medications but takes occasional NSAIDS for back pain
when needed.
Today’s Visit
Test
Result
Blood Pressure
160/90 mmHg
Weight
102 kg
BMI
31 kg/m2
Waist Circumference
110 cm
Chest Findings
Consistent with bronchitis - no clinical
signs of COPD
Case study - Larry
Today’s Visit
Larry’s GP found some of Larry’s results and history concerning. The GP
has asked you to review Larry’s case further, looking at his potential risk
for kidney disease.
Q1: Is Larry at increased risk of kidney
disease? If so, why?
Risk factors for kidney disease
Risk factors for CKD
Diabetes
High blood pressure
Smoking
Age over 60 years
Obesity
Aboriginal or Torres Strait Islander origin
Family history of kidney failure
Established cardiovascular disease
Larry has 5 of
the 8 risk
factors for
CKD
1 in 3 Australian adults is at increased risk of CKD
due to the above risk factors!
Diabetic kidney disease
Q1a: What does Larry’s diabetes mean for
his CKD risk?
• 20-40% of patients with Type 2 diabetes develop nephropathy,
which classically* occurs in 2 stages:
 Early nephropathy - microalbuminuria and normal-high GFR
 Overt nephropathy - macroalbuminuria and progressive
decline in GFR
* Recent data shows that 33% individuals with diabetes with
eGFR <60ml/min/1.73m2 do not have albuminuria, and for these
subjects, prognosis is similar to those with albuminuria1,2
1. Tapp RJ, Shaw J, Chadban SJ et al. Am J Kidney Dis 2004; 44:792-8
2. Agarwal et al, NDT 2011
Classical stages of diabetic kidney disease*
*Those with Type 2 diabetes may have overt nephropathy at presentation
GFR
normal
Albuminuria
normal
0
5
10
Duration of Diabetes (years)
15
CKD risk factors - Smoking
Q1b: How does smoking increase Larry’s
risk of CKD?
• Among individuals with diabetes, those who smoke
are more likely to get albuminuria and among those
with diabetic kidney disease, smoking accelerates
progression to failure [1,2]
• Even among the normal Australian population,
smoking has been associated with kidney damage [3]
[1] Gambaro et al. Diabetes Nutr Metab 2001;14:337.
[2] Orth & Hallan. Clin J Am Soc Nephrol 2007.
[3] Briganti et al. Am J Kidney Dis 2002;40:704.
CKD risk factors - Hypertension
Q1c: Larry has hypertension. What does
this mean for his CKD risk?
• Hypertension is extremely common among those with
type 2 diabetes, particularly those with DKD
• Among those with diabetes (and without), those with
hypertension are 5-8 times as likely to have albuminuria
• Achieving BP control is one of the most effective ways to
delay the progression of kidney disease
CKD risk factors - Obesity
Q1d: Larry is obese. What impact does his
weight have on his risk of CKD?
• Overweight (BMI 25.1-30) and obese (BMI >30) people are 40%
and 80% more likely to develop CKD compared to normal
weight individuals [1]
• Central obesity appears to be more important than generalised
• Although not as powerful as diabetes or hypertension as a risk
factor for kidney disease, obese subjects may be more likely to
develop albuminuria and proteinuria
• Obesity leads to greater difficulty in achieving tight glycaemic
control and BP control
[1] Wang Y et al. Association between obesity and kidney disease: a systematic review
and meta-analysis. Kidney Int. 2008;73:19-33.
CKD risk factors – NSAID use
Q1e: Does Larry’s occasional NSAID use
increase his risk of CKD?
Probably not!
• Chronic use of NSAIDs have not been proven to
lead to CKD in humans
• However, NSAID ingestion can aggravate
underlying kidney disease and hypertension and
 risk of vascular events
• Should be avoided in this setting
CKD risk factors – Chest infection
Q1f: Will Larry’s chest infection contribute
to his likelihood of CKD?
FALSE
• Chest infection by itself has no relationship to CKD
• Recurrent chest infections are more common in
smokers
• With this history of smoking Larry is highly likely
to develop COPD in the future
Checking for kidney damage
Larry is at increased risk of kidney disease and you decide to
test him for evidence of kidney damage.
Q2: How would you test Larry for evidence
of kidney damage?
?
?
?
?
?
?
urine dipstick for blood and protein
spot urine albumin/creatinine ratio (ACR)
24 hour urine protein
serum creatinine
eGFR
renal ultrasound (kidney outline and size)
Checking for kidney damage
Answer:
? urine dipstick for blood and protein
 spot urine albumin/creatinine ratio (ACR)
? 24 hour urine protein
 serum creatinine
 eGFR
? renal ultrasound (kidney outline and size)
Urine albumin /creatinine ratio (ACR)
•
The preferred urine test in all diabetics is to look for microalbuminuria
•
This is best tested by a urine albumin:creatinine ratio (ACR)
•
Preferably 1st morning void but a random sample can also be used
ACR Result
Test Results Range
Recommended Follow -up
Normal
Females <3.5 mg/mmol
Males <2.5 mg/mmol
Re-test annually
Microalbuminuria
Females
3.5 – 35 mg/mmol
Males
2.5 – 25 mg/mmol
Repeat 2 times over 3 months
Confirm microalbuminuria if 2 out of
3 tests are positive
Macroalbuminuria
Females >35 mg/mmol
Males >25 mg/mmol
Do a protein:creatinine ratio (PCR) or
24 hour urine protein (to quantify
protein excretion)
(also called proteinuria)
NHMRC Guidelines 2009
Serum Creatinine & eGFR
• The serum creatinine result (taking allowance for age and
sex) is converted to an eGFR automatically by all Australian
path labs and reported as numerical value or
>90mL/min/1.73m2.
• eGFR is accurate at values <60, but tends to underestimate
true GFR in those with diabetes with true GFR>60.
• Creatinine alone will commonly under-estimate the degree of
reduction in kidney function, particularly in small elderly
women.
Comparing eGFR and Creatinine
CKD 1&2
Serum
creatinine
CKD 3
120
90
Albuminuria
60
GFR mL/min
CKD 4 CKD 5
30
Normal Serum Creatinine Level
Actual Serum Creatinine Level
0
Dialysis
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 kidney failure
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
Summary of tests for kidney disease
Kidney Health Check
Blood Test
Urine Test
Creatinine & eGFR
Albumin /
Creatinine Ratio
(ACR) to check for
albuminuria
BP Check
Blood Pressure should
be consistently below
130/80 mmHg for
people with diabetes or
albuminuria
Case study - Larry
You identified Larry as being at increased risk for CKD and
requested he be recalled for further tests.
Larry’s tests results show the following:
Test
Creatinine
Result
135 µmol/L
eGFR
Urine ACR
HbA1c
Blood Pressure
46 mL/min/1.73m2
44 mg/mmol (macroalbuminuria)
9.6% / 81 mmol/mol
160/90 mmHg
Larry - kidney damage
Q3: What do you do about Larry’s high
blood pressure?
Hypertension control in diabetes
Answer
a)
Lifestyle approaches are the first consideration
in all people with diabetes and high blood
pressure - the key elements are:
 ‘SNAP’ (smoking, nutrition, alcohol, physical
activity)
 A low salt diet
 An exercise program
 A low calorie diet to reduce his BMI
 A reduction in his alcohol intake
 Stop smoking
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
Hypertension in diabetes
Answer
b) Medications may be needed to lower blood
pressure to target levels
 The preferred anti-hypertensive agents in
diabetes are an ACE-inhibitor or ARB
 These agents may also slow progression of CKD
 Any other anti-hypertensive agent that lowers
blood pressure down to target will improve the
patient’s future.
As Larry has diabetes and albuminuria, his blood pressure
should be maintained consistently below 130/80
Larry’s management plan
Q4: How could you improve Larry’s
diabetes control?
Good glycaemic control slows progression of kidney failure*
• Prescribe exercise and diet
• 44% of patients are on a sulphonylurea
• Metformin okay to use in reduced doses when eGFR is
between 30 and 60 mL/min - avoid use if GFR below 30
mL/min, due to risk of acidosis
• Consider referral to endocrinologist and diabetes
education centre
See Diabetes Australia website for guidelines:
www.diabetes.com.au
*UKPDS. Lancet 1998;352:837-53
How to incorporate CKD into your systems?
• Annual cycle of care
• Quarterly nursing review
• Annual nursing review
• GP management plans
• Team Care Arrangements
Diabetes - Annual cycle of care
Diabetes Management in General Practice 11/12
Quarterly Nursing Review
Quarterly Nursing Review – Routine Visit
Ask About:
Check:
Review:
•
•
•
•
•
Smoking
Nutrition
Alcohol intake
How much exercise and how often
Any problems with medication
•
•
•
•
Weight / Waist
Height (children & adolescents)
Blood Pressure
Feet examination without shoes, if new symptoms or
at risk (eg neuropathy+- peripheral vascular disease)
• Goals with patient to identify specific areas of focus for
doctor consultations
Diabetes Management in General Practice 11/12
Annual Nursing Review
Yearly Nursing Review – More detailed assessment
Ask About:
•
•
•
•
•
•
•
•
•
•
•
•
Smoking
Nutrition (last contact with dietician or diabetes educator)
Alcohol intake
How much exercise and how often
Any problems with medication
Any changes in medication (by doctor / pharmacist or patient)
Chest pain
Vision (when last checked)
Any foot discomfort
When was last podiatry check
Immunisations (include Flu and Pneumovax)
Family history and update
Check:
•
•
•
•
•
•
•
Weight / Waist
Height (children & adolescents)
Blood Pressure
Feet examination without shoes, pulses, monofilament check
Blood glucose at examination
Urinalysis
Visual Activity
Review:
• Goals with patient to identify specific areas of focus for doctor consultations
• Last care plan to identify timely referrals
Diabetes Management in General Practice 11/12
GP Management Plans (GPMP)
Medicare Australia has provided remuneration for chronic disease
management by the following item numbers:
• 721, 732, 729 & 732 for patient & GP Management of a single
or multiple chronic conditions that incorporate the patient’s
needs, goals, details of achievement & references to any
resources. Electronic templates are available via medical
software and Medicare Locals.
• 723, 732 & 10997 for involving other Health Professionals in
the Management Plan, including the Practice Nurse.
• For more information visit www.health.gov.au
Item 10997 - Practice Nurse & Aboriginal
Health Worker monitoring & support
For provision of monitoring & support to people with a chronic disease by a
practice nurse or registered Aboriginal Health Worker, on behalf of a GP.
• Available for people who have a GPMP / TCA
• A maximum of 5 services can be claimed per patient per calendar
year.
• The item may be used to provide:
• Checks on clinical progress (eGFRs, ACR, BP)
• Monitoring medication compliance (BP medication(s))
• Self management advice (BMI target, exercise, diet) and
• Collection of information to support GP reviews of Care Plans.
www.health.gov.au
Role of the practice nurse
Assist in the Management of CKD by
• Promote self management strategies (lifestyle modification)
• Assist with adherence to treatment to slow progression of CKD
• Screen and manage diabetes and hypertension
• Assessment of Absolute Cardiovascular Risk
www.cvdcheck.org.au
• Monitor for nephrotoxic medications (e.g. NSAIDs)
• Assess and manage symptoms (e.g. anaemia, nausea/vomiting)
• Monitoring and support under current Medicare Item Number(s)
Larry – GPMP
Q5: Which other health professionals
could you involve in your management of
Larry through a Team Care Arrangement?
Multidisciplinary Team
May include, but is not limited to:
•
•
•
•
•
Practice Nurse
•
General Practitioner
•
Dietitian
•
Family Members / Carers
•
Community Health (weight & •
diet programs specific to local •
community)
•
• Exercise Physiologist
•
• Quitline
•
•
•
Nephrologist
Optometrist/ Ophthalmologist
Endocrinologist
Diabetes Specialist
Renal Nurse
Nurse Practitioner
Pharmacist
Podiatrist
Social Worker
Vascular/ Transplant Surgeon
Cardiologist
Larry’s management plan
Q6: GPMPs recommend review every 3-6
months. What will you review when
Larry returns for his next visit?
Quarterly Nursing Review – Routine Visit
Ask About:
Check:
Review:
GPMP reviews
assist
behavioural
change.
Set up a recall /
reminder system
•
•
•
•
•
Smoking
Nutrition
Alcohol intake
How much exercise and how often
Check medications (prescribed & OTC)
•
•
•
•
Weight / Waist
Height (children & adolescents)
Blood Pressure
Feet examination without shoes, if new symptoms or at
risk (eg neuropathy+- peripheral vascular disease
• Goals with patient to identify specific areas of focus for
doctor consultations
Systems to identify patients with diabetes and CKD
• Practice nurses have opportunities to screen high risk
patients in the primary care setting
• Web based tools:
• eGFR calculator (www.kidney.org.au)
• Absolute CVD calculator (www.cvdcheck.org.au)
• Data extraction tools for general practice
• Pen Clinical Audit Tool (CAT), Canning Tool
• Link to most GP desktop systems
• Medicare Locals can provide access and support
Summary: CKD and diabetes
 All people with diabetes should have an annual kidney health check
 The targets of therapy (blood pressure, glycaemia etc) may differ in those
with DKD
 Major role for practice nurse in coordinating a multidisciplinary approach
 Kidney disease an integral part of chronic disease management
 Marked overlap with CVD risk reduction and diabetic strategies
 Encourage self management wherever possible
Potential to halve the number of patients presenting with kidney failure
Further Resources…
CKD Management in
General Practice
2012 Guidelines booklet
Diabetic Kidney Disease patient fact sheet
Available along with other kidney health fact sheets at
www.kidney.org.au > For Patients > Health Fact Sheets
Kidney Health Information Service
Free call information service for people living with / affected by kidney disease
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