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Detecting & Managing CKD Kidney Health Australia

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1 Detecting & Managing CKD Kidney Health Australia
2012 Chronic Kidney Disease & Diabetes for Primary Care Nurses All Modules 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

2 KCAT Supporters KCAT Program Partners KCAT Major Sponsor
The KCAT program is proudly supported by unrestricted educational grants from: KCAT Program Partners KCAT Major Sponsor ALL Modules 2

3 CKD & Diabetes for practice nurses - March 2012
14/04/2017 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 Please do not change the learning objectives for this session!

4 Chronic 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. OR Evidence of kidney damage (with or without decreased GFR) for ≥3 months: albuminuria haematuria after exclusion of urological causes pathological abnormalities anatomical 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.

5 Hypertension / Diabetes
Kidney Disease in Australia  Australians aged ≥ 18 years 5+ MILLION AT RISK 1,124,000 19,000 53,000 580,000 Dialysis or transplant Stage 4-5 CKD Stage 3 CKD Hypertension / Diabetes Stage 1 – 2 CKD Less than 10% of these people are aware they have CKD Australian Health Survey 2013; ABS population estimates June 2012 CKD staging is according to the CKD-EPI equation

6 The Australian CKD staging schema
X Please 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 Plan 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

7 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

8 CKD & Diabetes for practice nurses - March 2012
14/04/2017 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

9 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 Useful resource – NEFRON Study – available at > health professionals > publications *NEFRON Study 2007

10 The increasing burden of CKD and diabetes Australia - 1981 to 2009
Number of new patients with ESKD due to diabetes starting on dialysis From the ANZDATA registry Years from are on the x-axis Graph shows that number of new patients starting dialysis who have type 1 diabetes is relatively stable over the period The 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.

11 Diabetes is the cause of kidney failure that is largely driving the increase in dialysis patients in Australia In 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

12 Finding 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 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

13 CKD & Diabetes for practice nurses - March 2012
14/04/2017 Case Study Larry Modules – 2, 10

14 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

15 Case study - Larry Larry’s History Today’s Visit
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

16 Q1 : Is Larry at increased risk of kidney disease? If so, why?
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?

17 Larry has 5 of the 8 risk factors for CKD
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!

18 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

19 Duration of Diabetes (years)
Classical stages of diabetic kidney disease* *Those with Type 2 diabetes may have overt nephropathy at presentation normal GFR Albuminuria 5 10 15 Duration of Diabetes (years) As diabetes duration increases the eGFR is expected to decrease and albuminuria will increase

20 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.

21 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 Modules – 2, 10

22 CKD 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 [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 Modules – 2, 10 [1] Wang Y et al. Association between obesity and kidney disease: a systematic review and meta-analysis. Kidney Int. 2008;73:19-33.

23 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 Modules – 2, 10

24 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 Modules – 2, 10

25 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) Modules – 2, 10

26 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) Modules – 2, 10

27 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 (also called proteinuria) Females >35 mg/mmol Males >25 mg/mmol Do a protein:creatinine ratio (PCR) or 24 hour urine protein (to quantify protein excretion) Modules – 2, 10 NHMRC Guidelines 2009

28 CKD & Diabetes for practice nurses - March 2012
14/04/2017 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.

29 Comparing eGFR and Creatinine
Detecting & Managing CKD Kidney Health Australia 2012 Comparing eGFR and Creatinine CKD 1&2 CKD 5 CKD 4 CKD 3 GFR mL/min 120 90 60 30 Serum creatinine Normal Serum Creatinine Level This 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. Albuminuria Dialysis Actual Serum Creatinine Level

30 Who should be tested for kidney disease?
Risk Factor Recommended Tests Frequency Smoker Urine ACR eGFR Blood Pressure Every 1-2 years* Diabetes Hypertension Obesity Established cardiovascular disease Family history of kidney failure Aboriginal or Torres Strait Islander origin aged over 30 years This table summarises who should be tested for CKD and when they should be tested *yearly for people with diabetes or hypertension If an individual has multiple risk factors, follow the more frequent regime

31 Albumin / Creatinine Ratio (ACR) to check for albuminuria
Summary of tests for kidney disease Creatinine & eGFR Blood Pressure should be consistently below 130/80 mmHg for people with diabetes or albuminuria Albumin / Creatinine Ratio (ACR) to check for albuminuria Kidney Health Check Blood Test Urine Test BP Check Modules – 2, 10 Urine tests - Albuminuria the term albuminuria includes increased urinary excretion of albumin, increased urinary excretion of other proteins, and increased excretion of total urine protein It is very rare for an individual 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 Clinical Tip The 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 albuminuria Urine ACR accurately predicts renal and cardiovascular risks in population studies and reduction in urine ACR predicts renoprotective benefit in intervention trials Urine ACR exhibits greater sensitivity than protein:creatinine ratio (PCR) for detecting lower amounts of clinically important albuminuria A positive ACR test should be repeated on a first void sample to confirm persistence of albuminuria CKD is present if at least two out of three ACR tests (including the initial test) are positive If the first positive ACR is a random spot (as it may be for opportunistic testing), then repeat tests should ideally be first morning void specimens Dipsticks for protein in the urine are now no longer recommended for this purpose as their sensitivity and specificity is not optimal Urine PCR can be used for quantification and monitoring of proteinuria if required, but this is not preferred

32 Case 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: Test Result Creatinine 135 µmol/L eGFR 46 mL/min/1.73m2 Urine ACR 44 mg/mmol (macroalbuminuria) HbA1c 9.6% / 81 mmol/mol Blood Pressure 160/90 mmHg

33 Larry - kidney damage Q3: What do you do about Larry’s high blood pressure?

34 Hypertension control in diabetes
Answer 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

35 Lifestyle modification effects on BP
Detecting & Managing CKD Kidney Health Australia 2012 Lifestyle modification effects on BP Modification Recommendation Approx SBP reduction Weight reduction BMI 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

36 Hypertension in diabetes
Answer 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

37 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: *UKPDS. Lancet 1998;352:837-53

38 How to incorporate CKD into your systems?
CKD & Diabetes for practice nurses - March 2012 14/04/2017 How to incorporate CKD into your systems? Annual cycle of care Quarterly nursing review Annual nursing review GP management plans Team Care Arrangements These points will be discussed in detail over the next few slides

39 Diabetes - Annual cycle of care
CKD & Diabetes for practice nurses - March 2012 14/04/2017 Diabetes - Annual cycle of care Practice nurses will generally be aware of the diabetes annual cycle of care although may be involved to varying degrees. GPMP = GP management plan TCA = team care arrangement Diabetes Management in General Practice 11/12

40 Quarterly Nursing Review
CKD & Diabetes for practice nurses - March 2012 14/04/2017 Quarterly Nursing Review Quarterly Nursing Review – Routine Visit Ask About: Smoking Nutrition Alcohol intake How much exercise and how often Any problems with medication Check: Weight / Waist Height (children & adolescents) Blood Pressure Feet 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 consultations This 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 quarterly Diabetes Management in General Practice 11/12

41 CKD & Diabetes for practice nurses - March 2012
14/04/2017 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 Annual nursing review as recommended in the diabetes management in general practice booklet Purpose 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

42 GP Management Plans (GPMP)
Detecting & Managing CKD Kidney Health Australia 2012 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 & for involving other Health Professionals in the Management Plan, including the Practice Nurse. For more information visit General 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.

43 Detecting & Managing CKD Kidney Health Australia
Item 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. 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 progress Monitoring medication compliance Self management advice Collection 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.

44 Role of the practice nurse
Detecting & Managing CKD Kidney Health Australia 2012 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 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) Lifestyle advice Weight management (each 10kg decreases BP by 5-10mmHg) Smoking cessation Benefits of regular exercise Nutrition Reduce alcohol intake

45 Detecting & Managing CKD Kidney Health Australia
2012 Larry – GPMP Q5: Which other health professionals could you involve in your management of Larry through a Team Care Arrangement?

46 Multidisciplinary Team
Detecting & Managing CKD Kidney Health Australia 2012 Multidisciplinary Team May include, but is not limited to: Practice Nurse Nephrologist General Practitioner Optometrist/ Ophthalmologist Dietitian Endocrinologist Family Members / Carers Diabetes Specialist Community Health (weight & diet programs specific to local community) Renal Nurse Nurse Practitioner Pharmacist Exercise Physiologist Podiatrist Quitline Social Worker Vascular/ Transplant Surgeon Cardiologist

47 CKD & Diabetes for practice nurses - March 2012
14/04/2017 Larry’s management plan Q6: 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 system Quarterly Nursing Review – Routine Visit Ask About: Smoking Nutrition Alcohol intake How much exercise and how often Check medications (prescribed & OTC) Check: Weight / Waist Height (children & adolescents) Blood Pressure Feet 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 consultations Note: animation present in this slide

48 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 Data extraction tools are available Talk to your Medicare Local about what data extraction tools are available and how they can help

49 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

50 CKD Management in General Practice
Further Resources… CKD Management in General Practice 2012 Guidelines booklet All modules

51 Diabetic Kidney Disease patient fact sheet
Available along with other kidney health fact sheets at > For Patients > Health Fact Sheets

52 Kidney Health Information Service
Free call information service for people living with / affected by kidney disease All Modules

53 Join 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 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 All modules To join the kidney community,

54 Any Questions? All modules


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