Nurse leadership in
cardiovascular risk reduction in
Chronic Kidney
CVD riskDisease
reduction PN
KCAT Primary Care Nurse Workshop
This workshop was conceived and developed by the Kidney Check Australia Taskforce
with particular thanks to Professor Vlado Perkovic and modified for general practice nurses by KCAT subcommittee
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KCAT supporters
The KCAT program is proudly supported by unrestricted educational grants from:
KCAT Program Partners
KCAT Major Sponsor
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Learning outcomes
At the end of this workshop participants will be able to:
Understand the burden of Chronic Kidney Disease (CKD) in Australia and how
to screen for it with a ‘Kidney Health Check’
Understand the importance of addressing cardiovascular risk in patients with
chronic kidney disease (CKD)
Know the goals for management of CKD and Absolute Cardiovascular Risk and
integrate the knowledge learned into your practice
Have increased knowledge of the difference a CKD diagnosis will make to the
management strategies, treatment targets and therapy choices for patients
Improve patient safety outcomes by implementing nurse led systems to
routinely assess and manage cardiovascular risk in patients with or at risk of
CKD
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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.
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Chronic Kidney Disease (CKD) Management in General Practice, 2nd edition. Kidney Health Australia: Melbourne, 2012
CKD is a major public health problem
• 1 in 10 Australian adults has CKD
• Less than 10% of people with CKD are aware they have
the condition
• You can lose up to 90% of your kidney function before
experiencing any symptoms
• Major independent risk factor for cardiovascular disease
• Common, harmful & treatable
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Australian Health Survey, 2013
Chronic Kidney Disease (CKD) Management in General Practice, 2nd edition. Kidney Health Australia: Melbourne, 2012
Kidney disease in Australia
Australians aged ≥ 18 years
Dialysis or transplant
21,000
Less than
10% of these
people are
aware they
have CKD
Stage 4 - 5 CKD
54,000
591,000
Stage 3 CKD
Stage 1 - 2 CKD
1,146,000
5+ MILLION AT RISK
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Hypertension / Diabetes
Australian Health Survey 2013; ABS population estimates June 2013; ANZDATA 2012 Report
CKD staging is according to the CKD-EPI equation
Risk factors for kidney disease
Eight major risk factors for CKD
Diabetes
High blood pressure
Smoking
Obesity, BMI >30kg/m2
Age over 60 years
Aboriginal or Torres Strait Islander origin
Family history of kidney failure
Established cardiovascular disease
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1 in 3 Australian
adults is at increased
risk of CKD due to the
above risk factors
RACGP Guidelines for preventive activities in general practice 8th edition;
Chronic Kidney Disease (CKD) Management in General Practice, 2nd edition. Kidney Health Australia: Melbourne, 2012
Screening for CKD
Risk Factor
Recommended Tests
Frequency
Smoker
Diabetes
Hypertension
Every 1-2 years*
Obesity
Established cardiovascular disease
Family history of kidney failure
Urine ACR
eGFR
Blood Pressure
*annually for people
with diabetes or
hypertension
Aboriginal or Torres Strait Islander
origin aged over 30 years
Age over 60
This risk factor alone does not require regular
testing
If an individual has multiple risk factors, follow a more frequent regime
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RACGP Guidelines for preventive activities in general practice 8th edition;
Chronic Kidney Disease (CKD) Management in General Practice, 2nd edition. Kidney Health Australia: Melbourne, 2012
Kidney Health Check
Kidney Health Check
Blood Test
Urine Test
BP Check
eGFR
Albumin /
Creatinine
Ratio (ACR)
Blood pressure
calculated from
serum creatinine
to check for
albuminuria
*maintain
consistently below
BP goals
An eGFR < 60 mL/min/1.73m2 = increased risk of adverse renal, cardiovascular
and other clinical outcomes, IRRESPECTIVE OF AGE
N.B. Dipstick testing is not a sufficient test for CKD screening
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Chronic Kidney Disease (CKD) Management in General Practice, 2nd edition. Kidney Health Australia: Melbourne, 2012
What about abnormal results?
• If the eGFR or ACR results are abnormal they
will need to be repeated before CKD can be
diagnosed
• The following algorithm, along with your ‘CKD
management in general practice’ booklet, is a
useful reference
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Algorithm for detection of CKD
Diagnose CKD and use table to define stage
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Chronic Kidney Disease (CKD) Management in General Practice, 2nd edition. Kidney Health Australia: Melbourne, 2012
Staging CKD
Combine eGFR stage, albuminuria stage and
underlying diagnosis to specify CKD stage
(e.g. stage 3b CKD with microalbuminuria secondary to diabetic kidney disease)
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
Microalbuminuria
Macroalbuminuria
(urine ACR mg/mmol) (urine ACR mg/mmol) (urine ACR mg/mmol)
Male: < 2.5
Male: 2.5-25
Male: > 25
Female: < 3.5
Female: 3.5-35
Female: > 35
Not CKD unless
haematuria, structural
or pathological
abnormalities present
X
Colour-coded Clinical Action Plans
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Chronic Kidney Disease (CKD) Management in General Practice, 2nd edition. Kidney Health Australia: Melbourne, 2012
Cardiovascular risk reduction in CKD
• CKD is one of the most potent known risk factors for
cardiovascular disease
• It is essential to clinically determine the risk of CKD before
using the Australian absolute cardiovascular risk tool
(www.cvdcheck.org.au ) to accurately calculate
cardiovascular risk
• 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
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Chronic Kidney Disease (CKD) Management in General Practice, 2nd edition. Kidney Health Australia: Melbourne, 2012
Case study - Tony
Background
•
•
•
54 years old
Works in family retail business
Enjoys watching sport
Today
Tony sees you for his usual blood pressure
lowering prescription.
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Case study - Tony
Medical history
• High blood pressure, diagnosed 18 years ago
• Dyslipidaemia, diagnosed 6 months ago
•
Currently on trial of dietary management
• Chronic kidney disease:
•
•
•
Stage 3b CKD with microalbuminuria
6 months ago: eGFR 38 mL/min/1.73m2
urine ACR 21mg/mmol
• Knee osteoarthritis
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Case study - Tony
Previous
smoker:
Ceased smoking 8 years ago
after 25 pack-year history
Alcohol:
3-4 glasses of wine each week
Allergies:
Nil known
Medications:
Nifedipine SR 60 mg daily with
no side effects
Tony hasn’t always been interested in preventative care.
However... His cousin has just had a primary coronary angioplasty for
a MI aged 55 years, and he is worried this could happen to him.
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Case study - Tony
On examination
• BP 150/90 mmHg (145/95mmHg 3 months ago)
• Weight 86 kg, height 1.75m, BMI 28
Investigations
Fasting bloods
BSL
5.6 mmol/L
K+
4.2 mmol/L
Creatinine
165 µmol/L
eGFR
40 mL/min/1.73m2
Total cholesterol
6.7 mmol/L
HDL cholesterol
1.4 mmol/L
LDL cholesterol
3.2 mmol/L
Triglycerides
2.4 mmol/L
Urine ACR (early morning)
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22.6 mg/mmol
Case study – Question
Q1: How do you establish Tony’s risk of experiencing
a CVD event in the near future?
a)
Use individual risk factors to make the assessment and
treat each risk factor on its own merit
b) Assess absolute cardiovascular risk using Australian risk
calculator
c)
As Tony has stage 3b CKD he is clinically determined to be
at high risk of experiencing a CVD event in the next 5 years
d) Focus on hypertension as the most important risk factor
and manage that appropriately
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Absolute cardiovascular risk
• Is a measure of the risk of subsequent cardiovascular
events for a person based on a range of established risk
factors
Blood pressure, cholesterol, age, diabetes, smoking history
• A range of calculators are available, but most are based on
variants of the Framingham risk equation
• Recent unified guidelines were published by National
Vascular Disease Prevention Alliance (NVDPA) in Australia,
after approval by the NHMRC
• Australian risk calculator recommended:
www.cvdcheck.org.au
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CVD risk
Australian Absolute Cardiovascular Disease Risk Calculator
www.cvdcheck.org.au
Tony has an eGFR of 40 mL/min/1.73m2
He is at high risk (>15% chance) of a CVD event in next 5 yrs.
He should not have the Absolute CVD risk tool applied.
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CVD risk
anyone with…
•
•
•
•
•
eGFR < 45 mL/min/1.73m2 or persistent proteinuria
Diabetes and microalbuminuria
Diabetes and age > 60 years
Established cardiovascular disease
Familial hypercholesterolaemia or total cholesterol above
7.5
• Severe hypertension
– Systolic 180 mmHg or greater
– Diastolic 110 mmHg or greater
is already at the highest risk of a cardiovascular event
Therefore the calculator should not be used
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CVD risk
eGFR <60mL/min defines a coronary heart disease risk
greater than diabetes
CKD
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CKD defined as eGFR 15-59.5ml/min per 1.73m2
Diabetes
Tonelli, Lancet 2012
CVD risk - summary
• Lower eGFR is a strong predictor of increased CVD risk
• Higher urine albumin excretion also predicts increased risk
• The two provide independent information so that individuals
with both risk factors have the highest risk
• These markers are additional to the information provided by
traditional risk factors
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Case study - answer
a)
Use individual risk factors to make the assessment and
treat each risk factor on its own merit
b) Assess absolute cardiovascular risk using Australian risk
calculator
c) As Tony has stage 3b CKD he is clinically
determined to be at high risk of experiencing a
CVD event in the next 5 years
d) Focus on hypertension as the most important risk factor
and manage that appropriately
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Target blood pressure in adults
Blood pressure goals
Patient Group
People with....
Maintain BP consistently
BELOW (mmHg)
Albuminuria
<130/80
Diabetes
<130/80
Chronic Kidney Disease
<140/90
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KHA-Cari guidelines-Primary prevention of chronic kidney disease:Blood pressure target
Case study – Question
Q2: What could you (his nurse) do to assist in
reducing Tony’s risk of cardiovascular disease?
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Lifestyle effects on BP
Modification
Recommendation
Weight reduction
BMI 18-24.9 kg/m2
4.4mmHg (for 5.1kg
weight lost)
Dietary sodium
restriction
Reduce dietary sodium intake to no
more than 2.4g sodium(or 6g salt)
4-7 mmHg(for reduction
by 6g in daily salt intake)
DASH diet
Fruit, vegies, low saturated and total
fat
5.5-11.4 (5.5 for
normotensives 11.4 for
hypertensives)
Physical activity
Aerobic activity for 30-60mins/day,
3-5 days/week
5mmHg
3mmHg(For 67%
Moderate alcohol No more than 2 drinks per day (men)
reduction from baseline
consumption only or 1 drink per day(women)
of 3-6 drinks per day
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Tiberio MFrisoli et al Beyond salt; lifestyle modifications and blood pressure: European Heart Journal (2011) 32, 3081–3087 doi:10.1093/eurheartj/ehr379
Hypertension
Adequate BP management delays the progression of CKD
(reduces the GFR drop/year)
150/90
If Tony’s BP was consistently below target, his
GFR loss per year would be reduced by 62%
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Bakris et al., Am J Kid Disease, 2000
Blood pressure and medications
• CKD can cause /aggravate hypertension and hypertension can
contribute to the progression of CKD
• Maintaining blood pressure 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
• Consider organising a Home Medicines review (HMR)
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Case study – Tony
• The GP has prescribed Tony an ACE inhibitor and
an appointment is made for you, the practice
nurse, to see him
Q3: Discuss the role of the practice nurse in
monitoring Tony’s CKD, and cardiovascular
disease risk
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Chronic disease management
Medicare Australia has provided remuneration for chronic disease
management by the following item numbers:
GP Management Plan
Other Items
Items 721, 729 & 732
Items 723, 10997, 10986
For patient and GP management of chronic
disease
Item 715 for Aboriginal and Torres Strait
Islander Health Assessments
Incorporates patients goals, needs,
achievements and references to resources
Involves collaboration with other health
professionals in patient care
Electronic templates for specific conditions
are available
CKD template available at
kcat@kidney.org.au
For more information visit www.mbsonline.gov.au
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Case study - Tony
You discuss Tony’s management plan with him.
Tony…
• Suggests that his main issues are lack of exercise, nutrition
(hyperlipidaemia) and hypertension.
• Agrees that learning self management principles may assist
him
• plans to utilise his five services under GPMP/TCA by seeing
a dietitian and exercise physiologist
Dietary changes and exercise plans that form part of Tony’s
management are hoped to impact on his hyperlipidaemia and
hypertension, and reduce his BMI from 28 by your follow up
visit in 6 months time.
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Case study – Question
Tony returns for a follow-up appointment 6 months later
Q4: After 6 months of dietary therapy Tony’s lipid
results are not at target.
Would he benefit from statin therapy?
YES
There is strong evidence that lipid lowering in
people with CKD will decrease the risk of
atherosclerotic events
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CV events
SHARP results: 17% reduction in major atherosclerotic
events*
Proportion suffering event* (%)
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Risk ratio 0.83 (0.74 – 0.94)
Log rank p=0.0022
17% reduction
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in risk
Placebo
15
Eze/simv
10
*Major atherosclerotic events (coronary
death, MI, non-haemorrhagic stroke,
or any revascularization)
*Average 0.85mmol/L decrease in LDL-C
vs. placebo
5
0
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0
1
2
3
Years
of follow-up
4
5
Baigent et al, Lancet 2011
Case study - Tony
After 6 months of dietary therapy:
Investigations
Tony
ACVR Guidelines
Total cholesterol
7.0 mmol/L
<4 mmol/L
HDL cholesterol
1.0 mmol/L
1 mmol/L
LDL cholesterol
3.4 mmol/L
<2 mmol/L
Triglycerides
2.6 mmol/L
<2 mmol/L
Fasting bloods
• Both you and the dietitian reinforce Tony’s dietary
efforts
• You support Tony with commencement of
medication for cholesterol lowering after
reassuring him that the use of Lipids is ok in CKD
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Case study – Question
Q5: Is antiplatelet therapy routinely recommended as
CVD primary prevention in people with CKD?
Tony mentions his cousin is now taking aspirin daily
and asks if he should too.
a) Yes
b) No
c) Possibly – it is important to balance risks
against benefits
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Summary of CVD risk reduction in CKD
•
BP lowering and lipid lowering have evidence to support their
efficacy at reducing CVD risk in people with CKD
•
BP lowering may also protect against progressive kidney
disease, especially in people with albuminuria
•
Aspirin shown to reduce CVD risk in hypertensive people with
CKD in a single study*
Confirmation in other studies required
•
Aspirin likely increases bleeding risk, and this needs to be
balanced against the benefits at an individual level
•
Dual RAS blockade may be harmful and should not be
routinely used
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Jardine et al, JACC 2010
Case study – Question
Q6: Does knowing Tony’s CKD status impact on CVD
risk reduction management?
YES
• The CV risk categorisation using the Absolute Risk
Tool is misleading unless CKD status is known
• The targets of therapy (BP, anti-platelets) are
different if CKD is present
• The benefits of achieving targets in people with
CKD are in general greater and include reduction in
risk of progression to kidney failure
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Case study – Tony
What’s next for Tony?
As Tony has Stage 3b CKD with Microalbuminuria follow the
Orange clinical action plan outlined in the CKD Management
in general practice booklet.
Orange Clinical Action Plan
eGFR 30-59 mL/min/1.73m2 with microalbuminuria or
eGFR 30-44 with normoalbuminuria
• 3-6 monthly clinical review
• Continue with pharmacological and lifestyle interventions to reduce
absolute cardiovascular risk
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Screening and assessments
Screening - search* for patients at risk and invite patients for a health check
Health Assessments (Items 701, 703, 705, 707, 715)
Screen those at risk
Assessments
Diabetes
701
Family history of kidney
failure
703
Established CVD
705
High blood pressure
707
Obese (BMI >30kg/m2
715
Smoker
Aboriginal or Torres Strait
Islander origin
Health Checks
A type 2 diabetes risk
evaluation for people aged
40-49 years (inclusive) with a
high risk of developing type
2 diabetes as determined by
the Australian Type 2
Diabetes Risk Assessment
Tool – once every 3 years to
eligible patients
A health assessment for
people aged 45-49 years
(inclusive) who are at risk of
developing chronic disease –
once only to an eligible
patient
For more information visit www.mbsonline.gov.au
*Use data management tools such as ‘PEN CAT’ to help find patients at risk
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CKD screening and management
Kidney Health Check and CKD management should
become an integral part of Chronic Disease Management
and screening processes in your practice
• Screening and assessments
• Annual diabetes cycle of care
• Chronic disease management
• Team care
• Management reviews
Kidney Health Check = Blood, Urine, BP
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Lifestyle and referral pathways
• Give patient SNAP guidelines and relevant
education brochures on CKD (see www.kidney.org.au)
• Referral to exercise physiologist, dietitian
• Referral to local lifestyle intervention
programs (Check with Medicare Local)
• Encourage patient to practice self
management strategies and provide self
management support
• Home medicines review
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Conclusion
• You need to know the CKD status before assessing
Cardiovascular risk
• Moderate to severe CKD is a clinical determinant of high
Cardiovascular risk
• Ignorance of CKD status when assessing CVD risk using the
Absolute Risk Tool (or by any other means) may seriously
underestimate the CVD risk in an individual and lead to
incorrect management
• The benefit of CVD risk reduction in people with CKD is
proven and is increased with greater severity of CKD
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Key messages
• Established cardiovascular disease is one of the eight
major risk factors for CKD
• The role of the Practice Nurse is important in the early
detection and treatment of CKD
• Early detection may reduce the rate of progression of
kidney failure & cardiovascular risk by 20-50%
• Nurses can implement change and play a key role
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Resources
CKD management in general practice
2012 Guidelines booklet
Available at
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www.kcat.org.au
Resources
Guidelines for the assessment and management
of Absolute Cardiovascular Disease Risk
National Vascular Disease Prevention Alliance
Available at
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www.cvdcheck.org.au
Resources
CKD management guidelines for general practice
Available at
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www.kidney.org.au
Resources
CKD Patient fact sheets
Available along with more kidney health fact sheets at
www.kidney.org.au > For Patients > Health Fact Sheets
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Resources
Kidney Health Information Service
Free call information service for people living
with / affected by kidney disease
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this workshop
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form before leaving.
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