Presentation on theme: "Detecting & Managing CKD Kidney Health Australia"— Presentation transcript:
1Detecting & Managing CKD Kidney Health Australia 2012Chronic Kidney Disease & Diabetesfor Primary Care NursesAll ModulesPrimary Care Nurse WorkshopThis workshop was conceived and developed by the Kidney Check Australia Taskforcesub-committee for education in nursing in general practice, with particular thanks to the KCAT team.Version 04.14
2KCAT Supporters KCAT Program Partners KCAT Major Sponsor The KCAT program is proudly supported by unrestricted educational grants from:KCAT Program PartnersKCAT Major SponsorALL Modules2
3CKD & Diabetes for practice nurses - March 2012 14/04/2017Learning OutcomesAt 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 resultsUnderstand the adjustments to treatment targets and management of CKD in patients with diabetesUnderstand the signs of diabetic kidney disease and what role the practice nurse plays in its managementDevelop confidence to include CKD testing and management into the diabetes cycle of carePlease do not change the learning objectives for this session!
4Chronic kidney disease is defined as: 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.OREvidence of kidney damage (with or without decreased GFR) for ≥3 months:albuminuriahaematuria after exclusion of urological causespathological abnormalitiesanatomical abnormalities.Basically CKD is persistent damage to kidneys.The evidence of kidney damage is a GFR < 60 mL/min/1.73, microalbuminuria, proteinuria, haematuria, pathological abnormalities – such as an abnormal renal biopsy, or anatomical abnormalities – such as polycystic kidneys or scarring seen on ultrasound.
5Hypertension / Diabetes Kidney Disease in Australia Australians aged ≥ 18 years5+ MILLION AT RISK1,124,00019,00053,000580,000Dialysis or transplantStage 4-5 CKDStage 3 CKDHypertension / DiabetesStage 1 – 2 CKDLess than 10% of these people are aware they have CKDAustralian Health Survey 2013; ABS population estimates June 2012CKD staging is according to the CKD-EPI equation
6The Australian CKD staging schema XPlease note this slide is animated.This table shows how to use the urine ACR result and the eGFR results, and where the results intersect in the table iindicates the appropriate Clinical Action PlanCombine 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
7Diabetic 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 damageDKD increases the risk of cardiovascular diseaseIt usually has no symptoms until it is well advanced
8CKD & Diabetes for practice nurses - March 2012 14/04/2017Diabetic Kidney Disease (DKD)DKD is the most frequent cause of kidney failure worldwideDKD is associated with increased morbidity and mortality at all stages of CKDEarly detection and comprehensive management of DKD is associated with improved outcomesCKD best care overlaps fully with cardiovascular risk reduction and best diabetes care
9CKD and diabetesEvery second patient you see with Type 2 diabetes will have CKD (47%)*A patient with diabetes has CKD if they have:Persistent microalbuminuria or proteinuriaAn eGFR < 60mL/min/1.73m2 and/orHaematuria after exclusion of urological causes or structural abnormalitiesUseful resource – NEFRON Study – available at > health professionals > publications*NEFRON Study 2007
10The increasing burden of CKD and diabetes Australia - 1981 to 2009 Number of new patients with ESKD due to diabetes starting on dialysisFrom the ANZDATA registryYears from are on the x-axisGraph shows that number of new patients starting dialysis who have type 1 diabetes is relatively stable over the periodThe number of new patients starting on dialysis who have type 2 diabetes has increased dramatically and is responsible for the increase in patients with diabetes starting dialysis.
11Diabetes is the cause of kidney failure that is largely driving the increase in dialysis patients in AustraliaIn the period 1998 – 2008 the number of dialysis patients in Australia has increased. This graph looks at the cause of people’s kidney failure over this period. It can be seen that all other causes such as BP, GN, refulx etc cause kidney failure at roughly the same rate per million people in 2008 as what they did in When looking at the red line that is diabetes as the cause of kidney failure the rate pmp has increased dramatically. This increase in the number of people with kidney failure caused by diabetes is almost solely responsible for increasing the number of dialysis patients in Australia over this period.ANZDATA Registry
12Finding an eGFR < 60 really means: 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 strokeLess likely to survive a heart attackMore likely to be hospitalised in next 12 monthsLikely to have heart failureWounds will heal more slowlyAnkle swelling and fluid retention are more difficult to controlBP targets more difficult to achieveHigher likelihood of fractures with a fallAdverse drug reactions more commonWhile blood sugar levels easier to control – more likely to have a hypo*NEFRON Study 2007
13CKD & Diabetes for practice nurses - March 2012 14/04/2017Case Study LarryModules – 2, 10
14Case study - Larry Background Larry is a 62 year old male of Caucasian backgroundHe works full-time as a clerk in the Public ServiceLarry presents at your general practice with an acute cough with yellow sputumHe has previously been seen at your practice when he accompanied his wife for an annual flu vaccination
15Case study - Larry Larry’s History Today’s Visit Larry has Type 2 diabetes that was diagnosed elsewhere a year ago after he presented with thirstSmoking - 40 pack years (1 pack per day for 40 years)Alcohol - consumes 7-10 drinks per weekFollows a “diabetic diet”Is on no regular medications but takes occasional NSAIDS for back pain when needed.Today’s VisitTestResultBlood Pressure160/90 mmHgWeight102 kgBMI31 kg/m2Waist Circumference110 cmChest FindingsConsistent with bronchitis - no clinical signs of COPD
16Q1 : Is Larry at increased risk of kidney disease? If so, why? Case study - LarryToday’s VisitLarry’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?
17Larry has 5 of the 8 risk factors for CKD Risk factors for kidney diseaseRisk factors for CKDDiabetesHigh blood pressureSmokingAge over 60 yearsObesityAboriginal or Torres Strait Islander originFamily history of kidney failureEstablished cardiovascular diseaseLarry has 5 of the 8 risk factors for CKD1 in 3 Australian adults is at increased risk of CKD due to the above risk factors!
18Diabetic 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 GFROvert 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 albuminuria1,21. Tapp RJ, Shaw J, Chadban SJ et al. Am J Kidney Dis 2004; 44:792-82. Agarwal et al, NDT 2011
19Duration of Diabetes (years) Classical stages of diabetic kidney disease**Those with Type 2 diabetes may have overt nephropathy at presentationnormalGFRAlbuminuria51015Duration of Diabetes (years)As diabetes duration increases the eGFR is expected to decrease and albuminuria will increase
20CKD 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  Gambaro et al. Diabetes Nutr Metab 2001;14:337. Orth & Hallan. Clin J Am Soc Nephrol 2007. Briganti et al. Am J Kidney Dis 2002;40:704.
21CKD 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 DKDAmong those with diabetes (and without), those with hypertension are 5-8 times as likely to have albuminuriaAchieving BP control is one of the most effective ways to delay the progression of kidney diseaseModules – 2, 10
22CKD risk factors - Obesity Q1d: Larry is obese. What impact does his weight have on his risk of CKD?Overweight (BMI ) and obese (BMI >30) people are 40% and 80% more likely to develop CKD compared to normal weight individuals Central obesity appears to be more important than generalisedAlthough not as powerful as diabetes or hypertension as a risk factor for kidney disease, obese subjects may be more likely to develop albuminuria and proteinuriaObesity leads to greater difficulty in achieving tight glycaemic control and BP controlModules – 2, 10 Wang Y et al. Association between obesity and kidney disease: a systematic review and meta-analysis. Kidney Int. 2008;73:19-33.
23CKD 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 humansHowever, NSAID ingestion can aggravate underlying kidney disease and hypertension and risk of vascular eventsShould be avoided in this settingModules – 2, 10
24CKD risk factors – Chest infection Q1f: Will Larry’s chest infection contribute to his likelihood of CKD?FALSEChest infection by itself has no relationship to CKDRecurrent chest infections are more common in smokersWith this history of smoking Larry is highly likely to develop COPD in the futureModules – 2, 10
25Checking 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 proteinspot urine albumin/creatinine ratio (ACR)24 hour urine proteinserum creatinineeGFRrenal ultrasound (kidney outline and size)Modules – 2, 10
26Checking for kidney damage Answer:urine dipstick for blood and proteinspot urine albumin/creatinine ratio (ACR)24 hour urine proteinserum creatinineeGFRrenal ultrasound (kidney outline and size)Modules – 2, 10
27Urine albumin /creatinine ratio (ACR) The preferred urine test in all diabetics is to look for microalbuminuriaThis is best tested by a urine albumin:creatinine ratio (ACR)Preferably 1st morning void but a random sample can also be usedACR ResultTest Results RangeRecommended Follow -upNormalFemales <3.5 mg/mmolMales <2.5 mg/mmolRe-test annuallyMicroalbuminuriaFemales3.5 – 35 mg/mmolMales2.5 – 25 mg/mmolRepeat 2 times over 3 months Confirm microalbuminuria if 2 out of 3 tests are positiveMacroalbuminuria (also called proteinuria)Females >35 mg/mmolMales >25 mg/mmolDo a protein:creatinine ratio (PCR) or 24 hour urine protein (to quantify protein excretion)Modules – 2, 10NHMRC Guidelines 2009
28CKD & Diabetes for practice nurses - March 2012 14/04/2017Serum Creatinine & eGFRThe 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.
29Comparing eGFR and Creatinine Detecting & Managing CKD Kidney Health Australia2012Comparing eGFR and CreatinineCKD 1&2CKD 5CKD 4CKD 3GFR mL/min120906030Serum creatinineNormal Serum Creatinine LevelThis graph is showing that as GFR declines, serum creatinine rises (as shown by the red line).It highlights that there can be a 50% reduction in GFR before serum creatinine levels go outside the ‘normal’ range. This is why it is important to look at the GFR.What is CKD?CKD is usually a gradual process that occurs over at least several years, with loss of renal function from normal levels of over 90 mLs/min towards symptomatic uremia with GFR of less than 10 mls/min.In this lecture I will use terminology: End-stage kidney disease (ESKD) and Chronic kidney disease (CKD)This graph shows renal function on the x axis against serum creatinine, the most commonly used measure of renal function, on the y axis.Albuminuria, detected with a simple dipstick test of urine, may pick up early renal disease without significant loss of renal function.Serum creatinine does not rise above normal until about ½ renal function is lost.Dialysis is normally started in Australia at GFR below 10 ml/min.ESKD is the irreversible pre-terminal phase of CKD. Without maintenance dialysis or transplantation cannot sustain life. Estimates of treated ESKD incidence and prevalence available from national data registries. In Australia we have virtually complete capture of people receiving maintenance dialysis or with kidney transplants.CKD is the state of reduced kidney function not severe enough to require dialysis or transplantation, but sufficient cause metabolic problems leading to bone disease, vascular disease, anaemia etc.AlbuminuriaDialysisActual Serum Creatinine Level
30Who should be tested for kidney disease? Risk FactorRecommended TestsFrequencySmokerUrine ACReGFRBlood PressureEvery 1-2 years*DiabetesHypertensionObesityEstablished cardiovascular diseaseFamily history of kidney failureAboriginal or Torres Strait Islander origin aged over 30 yearsThis table summarises who should be tested for CKD and when they should be tested*yearly for people with diabetes or hypertensionIf an individual has multiple risk factors, follow the more frequent regime
31Albumin / Creatinine Ratio (ACR) to check for albuminuria Summary of tests for kidney diseaseCreatinine & eGFRBlood Pressure should be consistently below 130/80 mmHg for people with diabetes or albuminuriaAlbumin / Creatinine Ratio (ACR) to check for albuminuriaKidney Health CheckBlood TestUrine TestBP CheckModules – 2, 10Urine tests - Albuminuriathe term albuminuria includes increased urinary excretion of albumin, increased urinary excretion of other proteins, and increased excretion of total urine proteinIt is very rare for an individual to have increased excretion of non-albumin proteins without concomitant increased excretion of albuminExcessive amounts of proteins in the urine are a key marker of kidney damage and of increased renal and cardiovascular disease riskThese proteins are mainly albumin (albuminuria), but also consist of low molecular weight immunoglobulin, lysozyme, insulin and beta-2 microglobulinClinical TipThe preferred method for assessment of albuminuria in both diabetes and non-diabetes 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.How to detect albuminuriaUrine ACR accurately predicts renal and cardiovascular risks in population studies and reduction in urine ACR predicts renoprotective benefit in intervention trialsUrine ACR exhibits greater sensitivity than protein:creatinine ratio (PCR) for detecting lower amounts of clinically important albuminuriaA positive ACR test should be repeated on a first void sample to confirm persistence of albuminuriaCKD is present if at least two out of three ACR tests (including the initial test) are positiveIf the first positive ACR is a random spot (as it may be for opportunistic testing), then repeat tests should ideally be first morning void specimensDipsticks for protein in the urine are now no longer recommended for this purpose as their sensitivity and specificity is not optimalUrine PCR can be used for quantification and monitoring of proteinuria if required, but this is not preferred
32Case study - Larry Test Result Creatinine 135 µmol/L eGFR 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:TestResultCreatinine135 µmol/LeGFR46 mL/min/1.73m2Urine ACR44 mg/mmol (macroalbuminuria)HbA1c9.6% / 81 mmol/molBlood Pressure160/90 mmHg
33Larry - kidney damageQ3: What do you do about Larry’s high blood pressure?
34Hypertension control in diabetes AnswerLifestyle 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 dietAn exercise programA low calorie diet to reduce his BMIA reduction in his alcohol intakeStop smoking
35Lifestyle modification effects on BP Detecting & Managing CKD Kidney Health Australia2012Lifestyle modification effects on BPModificationRecommendationApprox SBP reductionWeight reductionBMI kg/m25-20 mmHg / 10kg lostDietary salt restriction<100 mmol/day2-8 mmHgDASH* dietFruit, vegies, low saturated and total fat8-14 mmHgPhysical activityAerobic activity for 30mins most days4-9 mmHgModerate alcohol consumption only1-2 standard drinks/day2-4 mmHg* Dietary Approaches to Stop Hypertension
36Hypertension in diabetes AnswerMedications may be needed to lower blood pressure to target levelsThe preferred anti-hypertensive agents in diabetes are an ACE-inhibitor or ARBThese agents may also slow progression of CKDAny 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
37Larry’s management plan Q4: How could you improve Larry’s diabetes control?Good glycaemic control slows progression of kidney failure*Prescribe exercise and diet44% of patients are on a sulphonylureaMetformin 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 acidosisConsider referral to endocrinologist and diabetes education centreSee Diabetes Australia website for guidelines:*UKPDS. Lancet 1998;352:837-53
38How to incorporate CKD into your systems? CKD & Diabetes for practice nurses - March 201214/04/2017How to incorporate CKD into your systems?Annual cycle of careQuarterly nursing reviewAnnual nursing reviewGP management plansTeam Care ArrangementsThese points will be discussed in detail over the next few slides
39Diabetes - Annual cycle of care CKD & Diabetes for practice nurses - March 201214/04/2017Diabetes - Annual cycle of carePractice nurses will generally be aware of the diabetes annual cycle of care although may be involved to varying degrees.GPMP = GP management planTCA = team care arrangementDiabetes Management in General Practice 11/12
40Quarterly Nursing Review CKD & Diabetes for practice nurses - March 201214/04/2017Quarterly Nursing ReviewQuarterly Nursing Review – Routine VisitAsk About:SmokingNutritionAlcohol intakeHow much exercise and how oftenAny problems with medicationCheck:Weight / WaistHeight (children & adolescents)Blood PressureFeet examination without shoes, if new symptoms or at risk (eg neuropathy+- peripheral vascular disease)Review:Goals with patient to identify specific areas of focus for doctor consultationsThis is the quarterly nursing review as recommended in the diabetes management in general practice book. The purpose of this slide and the following one is to demonstrate how a kidney health check fits within the diabetes cycle of care. Ie BP check quarterlyDiabetes Management in General Practice 11/12
41CKD & Diabetes for practice nurses - March 2012 14/04/2017Annual Nursing ReviewYearly Nursing Review – More detailed assessmentAsk About:SmokingNutrition (last contact with dietician or diabetes educator)Alcohol intakeHow much exercise and how oftenAny problems with medicationAny changes in medication (by doctor / pharmacist or patient)Chest painVision (when last checked)Any foot discomfortWhen was last podiatry checkImmunisations (include Flu and Pneumovax)Family history and updateCheck:Weight / WaistHeight (children & adolescents)Blood PressureFeet examination without shoes, pulses, monofilament checkBlood glucose at examinationUrinalysisVisual ActivityReview:Goals with patient to identify specific areas of focus for doctor consultationsLast care plan to identify timely referralsAnnual nursing review as recommended in the diabetes management in general practice bookletPurpose of table in this context is to demonstrate how a kidney health check fits into the diabetes cycle of care.They are already recommending BP and urinalysis – these are task that the nurse can perform – the GP would order blood tests and ACR – the nurse can remind the GP to do this however!Diabetes Management in General Practice 11/12
42GP Management Plans (GPMP) Detecting & Managing CKD Kidney Health Australia2012GP 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 & for involving other Health Professionals in the Management Plan, including the Practice Nurse.For more information visitGeneral Practice Management plans are set up by the GP but often involve the practice nurse. If a patient has diabetes and CKD then the GP might consider setting up a GP management plan.
43Detecting & Managing CKD Kidney Health Australia Item Practice Nurse & Aboriginal Health Worker monitoring & supportFor 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 / TCAA 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) andCollection of information to support GP reviews of Care Plans.Item came into effect from 1 July It covers the provision of monitoring and support to people with a chronic disease by a practice nurse or registered Aboriginal health worker on behalf of a GP.The objective of the initiative is to better utilise practice nurses in chronic disease management, which will help free up GPs to spend more time with patients on complex care. It is aimed at improved access and outcomes for patients, particularly in areas of workforce shortage.The item is available to people with a chronic disease, who have a GPMP, TCAs or Multidisciplinary Care Plan in place. It will assist patients who require access to ongoing care, frequently, for relatively routine treatment and ongoing monitoring and support between the more structured reviews of the care plan by the GP.The item is intended to provide sufficient flexibility for the provision of services appropriate for the patient’s care. Suitable services may include:Checks on clinical progressMonitoring medication complianceSelf management adviceCollection of information to support GP reviews of Care Plans.The item is claimed by the GP. In line with existing practice nurse and registered AHW items, the service is provided by the practice nurse or registered AHW on behalf of the GP.
44Role of the practice nurse Detecting & Managing CKD Kidney Health Australia2012Role of the practice nurseAssist in the Management of CKD byPromote self management strategies (lifestyle modification)Assist with adherence to treatment to slow progression of CKDScreen and manage diabetes and hypertensionAssessment of Absolute Cardiovascular RiskMonitor for nephrotoxic medications (e.g. NSAIDs)Assess and manage symptoms (e.g. anaemia, nausea/vomiting)Monitoring and support under current Medicare Item Number(s)Lifestyle adviceWeight management (each 10kg decreases BP by 5-10mmHg)Smoking cessationBenefits of regular exerciseNutritionReduce alcohol intake
45Detecting & Managing CKD Kidney Health Australia 2012Larry – GPMPQ5: Which other health professionals could you involve in your management of Larry through a Team Care Arrangement?
46Multidisciplinary Team Detecting & Managing CKD Kidney Health Australia2012Multidisciplinary TeamMay include, but is not limited to:Practice NurseNephrologistGeneral PractitionerOptometrist/ OphthalmologistDietitianEndocrinologistFamily Members / CarersDiabetes SpecialistCommunity Health (weight & diet programs specific to local community)Renal NurseNurse PractitionerPharmacistExercise PhysiologistPodiatristQuitlineSocial WorkerVascular/ Transplant SurgeonCardiologist
47CKD & Diabetes for practice nurses - March 2012 14/04/2017Larry’s management planQ6: GPMPs recommend review every 3-6 months. What will you review when Larry returns for his next visit?GPMP reviews assist behavioural change.Set up a recall / reminder systemQuarterly Nursing Review – Routine VisitAsk About:SmokingNutritionAlcohol intakeHow much exercise and how oftenCheck medications (prescribed & OTC)Check:Weight / WaistHeight (children & adolescents)Blood PressureFeet examination without shoes, if new symptoms or at risk (eg neuropathy+- peripheral vascular diseaseReview:Goals with patient to identify specific areas of focus for doctor consultationsNote: animation present in this slide
48Systems to identify patients with diabetes and CKD Practice nurses have opportunities to screen high risk patients in the primary care settingWeb based tools:eGFR calculator (www.kidney.org.au)Absolute CVD calculator (www.cvdcheck.org.au)Data extraction tools for general practicePen Clinical Audit Tool (CAT), Canning ToolLink to most GP desktop systemsMedicare Locals can provide access and supportData extraction tools are availableTalk to your Medicare Local about what data extraction tools are available and how they can help
49Summary: CKD and diabetes All people with diabetes should have an annual kidney health checkThe targets of therapy (blood pressure, glycaemia etc) may differ in those with DKDMajor role for practice nurse in coordinating a multidisciplinary approachKidney disease an integral part of chronic disease managementMarked overlap with CVD risk reduction and diabetic strategiesEncourage self management wherever possiblePotential to halve the number of patients presenting with kidney failure
50CKD Management in General Practice Further Resources…CKD Management in General Practice2012 Guidelines bookletAll modules
51Diabetic Kidney Disease patient fact sheet Available along with other kidney health fact sheets at > For Patients > Health Fact Sheets
52Kidney Health Information Service Free call information service for people living with / affected by kidney diseaseAll Modules
53Join the Kidney Community… KIDNEY COMMUNITY members receive a monthly newsletter from KHA allowing you to access:Information and invitations to KHA's education and support activitiesUpdates on medical research in kidney diseaseUpdates on clinical trials and research opportunitiesInformation on advocacy opportunities and government relations issuesInformation on community and corporate events held by Kidney Health AustraliaAll modulesTo join the kidney community,