1. 11 CVD risk 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 V0914 Nurse leadership in cardiovascular risk reduction in Chronic Kidney Disease

2. 22 KCAT supporters The KCAT program is proudly supported by unrestricted educational grants from: KCAT Program Partners KCAT Major Sponsor

3. 33 Learning outcomes 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 At the end of this workshop participants will be able to:

4. 444 What is CKD? Chronic kidney disease is defined as: Glomerular Filtration Rate (GFR) < 60 mL/min/1.73m 2 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. Chronic Kidney Disease (CKD) Management in General Practice, 2 nd edition. Kidney Health Australia: Melbourne, 2012

5. 555 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 Australian Health Survey, 2013 Chronic Kidney Disease (CKD) Management in General Practice, 2 nd edition. Kidney Health Australia: Melbourne, 2012

6. 666 Australians aged ≥ 18 years Australian Health Survey 2013; ABS population estimates June 2013; ANZDATA 2012 Report CKD staging is according to the CKD-EPI equation 5+ MILLION AT RISK 1,146,000 21,000 54,000 591,000 Dialysis or transplant Less than 10% of these people are aware they have CKD Stage 4 - 5 CKD Stage 3 CKD Stage 1 - 2 CKD Hypertension / Diabetes Kidney disease in Australia

7. 777 1 in 3 Australian adults is at increased risk of CKD due to the above risk factors Eight major risk factors for CKD Diabetes High blood pressure Smoking Obesity, BMI >30kg/m 2 Age over 60 years Aboriginal or Torres Strait Islander origin Family history of kidney failure Established cardiovascular disease RACGP Guidelines for preventive activities in general practice 8 th edition; Chronic Kidney Disease (CKD) Management in General Practice, 2 nd edition. Kidney Health Australia: Melbourne, 2012 Risk factors for kidney disease

8. 888 Screening for CKD Risk FactorRecommended TestsFrequency Smoker Urine ACR eGFR Blood Pressure Every 1-2 years* *annually for people with diabetes or hypertension Diabetes Hypertension Obesity Established cardiovascular disease Family history of kidney failure 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 RACGP Guidelines for preventive activities in general practice 8 th edition; Chronic Kidney Disease (CKD) Management in General Practice, 2 nd edition. Kidney Health Australia: Melbourne, 2012

9. 999 eGFR calculated from serum creatinine Blood pressure *maintain consistently below BP goals Albumin / Creatinine Ratio (ACR) to check for albuminuria Kidney Health Check Blood TestUrine TestBP Check N.B. Dipstick testing is not a sufficient test for CKD screening An eGFR < 60 mL/min/1.73m2 = increased risk of adverse renal, cardiovascular and other clinical outcomes, IRRESPECTIVE OF AGE Kidney Health Check Chronic Kidney Disease (CKD) Management in General Practice, 2 nd edition. Kidney Health Australia: Melbourne, 2012

10. 10 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 What about abnormal results?

11. 11 Diagnose CKD and use table to define stage Algorithm for detection of CKD Chronic Kidney Disease (CKD) Management in General Practice, 2 nd edition. Kidney Health Australia: Melbourne, 2012

12. 12 Staging CKD Albuminuria Stage GFR Stage GFR (mL/min/1.73m 2 ) Normal (urine ACR mg/mmol) Male: < 2.5 Female: < 3.5 Microalbuminuria (urine ACR mg/mmol) Male: 2.5-25 Female: 3.5-35 Macroalbuminuria (urine ACR mg/mmol) Male: > 25 Female: > 35 1 ≥90 Not CKD unless haematuria, structural or pathological abnormalities present 2 60-89 3a 45-59 3b 30-44 4 15-29 5 <15 or on dialysis Colour-coded Clinical Action Plans 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) Chronic Kidney Disease (CKD) Management in General Practice, 2 nd edition. Kidney Health Australia: Melbourne, 2012

13. 13 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 riskwww.cvdcheck.org.au 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 Cardiovascular risk reduction in CKD Chronic Kidney Disease (CKD) Management in General Practice, 2 nd edition. Kidney Health Australia: Melbourne, 2012

14. 14 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.

15. 15 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/1.73m 2 urine ACR 21mg/mmol Knee osteoarthritis Case study - Tony

16. 16 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.

17. 17 On examination BP 150/90 mmHg (145/95mmHg 3 months ago) Weight 86 kg, height 1.75m, BMI 28 Case study - Tony Investigations Fasting bloods BSL5.6 mmol/L K+K+ 4.2 mmol/L Creatinine165 µmol/L eGFR40 mL/min/1.73m 2 Total cholesterol6.7 mmol/L HDL cholesterol1.4 mmol/L LDL cholesterol3.2 mmol/L Triglycerides2.4 mmol/L Urine ACR (early morning)22.6 mg/mmol

18. 18 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

19. 19 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

20. 20 CVD risk Australian Absolute Cardiovascular Disease Risk Calculator www.cvdcheck.org.au Tony has an eGFR of 40 mL/min/1.73m 2 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. Tony has an eGFR of 40 mL/min/1.73m 2 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.

21. 21 anyone with… eGFR < 45 mL/min/1.73m 2 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 CVD risk

22. 22 CVD risk eGFR <60mL/min defines a coronary heart disease risk greater than diabetes Tonelli, Lancet 2012 CKD defined as eGFR 15-59.5ml/min per 1.73m 2 CKD Diabetes

23. 23 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 CVD risk - summary

24. 24 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

25. 25 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 KHA-Cari guidelines-Primary prevention of chronic kidney disease:Blood pressure target

26. 26 Case study – Question Q2: What could you (his nurse) do to assist in reducing Tony’s risk of cardiovascular disease?

27. 27 Tiberio MFrisoli et al Beyond salt; lifestyle modifications and blood pressure: European Heart Journal (2011) 32, 3081–3087 doi:10.1093/eurheartj/ehr379 ModificationRecommendation Weight reduction BMI 18-24.9 kg/m 2 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 Moderate alcohol consumption only No more than 2 drinks per day (men) or 1 drink per day(women) 3mmHg(For 67% reduction from baseline of 3-6 drinks per day Lifestyle effects on BP

28. 28 150/90 Bakris et al., Am J Kid Disease, 2000 If Tony’s BP was consistently below target, his GFR loss per year would be reduced by 62% Adequate BP management delays the progression of CKD (reduces the GFR drop/year) Hypertension

29. 29 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)

30. 30 Case study – Tony Q3: Discuss the role of the practice nurse in monitoring Tony’s CKD, and cardiovascular disease risk The GP has prescribed Tony an ACE inhibitor and an appointment is made for you, the practice nurse, to see him

31. 31 Chronic disease management Medicare Australia has provided remuneration for chronic disease management by the following item numbers: For more information visit www.mbsonline.gov.auwww.mbsonline.gov.au GP Management Plan Items 721, 729 & 732 For patient and GP management of chronic disease Incorporates patients goals, needs, achievements and references to resources Electronic templates for specific conditions are available CKD template available at kcat@kidney.org.au Other Items Items 723, 10997, 10986 Item 715 for Aboriginal and Torres Strait Islander Health Assessments Involves collaboration with other health professionals in patient care

32. 32 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.

33. 33 Case study – Question Q4: After 6 months of dietary therapy Tony’s lipid results are not at target. Would he benefit from statin therapy? Tony returns for a follow-up appointment 6 months later YES There is strong evidence that lipid lowering in people with CKD will decrease the risk of atherosclerotic events

34. 34 SHARP results: 17% reduction in major atherosclerotic events* Years of follow-up 012345 0 5 10 15 20 25 Proportion suffering event* (%) Risk ratio 0.83 (0.74 – 0.94) Log rank p=0.0022 Placebo Eze/simv Baigent et al, Lancet 2011 *Major atherosclerotic events (coronary death, MI, non-haemorrhagic stroke, or any revascularization) *Average 0.85mmol/L decrease in LDL-C vs. placebo 17% reduction in risk CV events

35. 35 Case study - Tony InvestigationsTonyACVR Guidelines Fasting bloods Total cholesterol7.0 mmol/L<4 mmol/L HDL cholesterol1.0 mmol/L  1 mmol/L LDL cholesterol3.4 mmol/L<2 mmol/L Triglycerides2.6 mmol/L<2 mmol/L 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 After 6 months of dietary therapy:

36. 36 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

37. 37 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 Jardine et al, JACC 2010

38. 38 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 Case study – Question Q6: Does knowing Tony’s CKD status impact on CVD risk reduction management?

39. 39 As Tony has Stage 3b CKD with Microalbuminuria follow the Orange clinical action plan outlined in the CKD Management in general practice booklet. 3-6 monthly clinical review Continue with pharmacological and lifestyle interventions to reduce absolute cardiovascular risk Case study – Tony What’s next for Tony? Orange Clinical Action Plan eGFR 30-59 mL/min/1.73m 2 with microalbuminuria or eGFR 30-44 with normoalbuminuria

40. 40 Screening and assessments Screen those at risk Diabetes Family history of kidney failure Established CVD High blood pressure Obese (BMI >30kg/m 2 Smoker Aboriginal or Torres Strait Islander origin Assessments 701 703 705 707 715 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 Screening - search* for patients at risk and invite patients for a health check Health Assessments (Items 701, 703, 705, 707, 715) *Use data management tools such as ‘PEN CAT’ to help find patients at risk For more information visit www.mbsonline.gov.auwww.mbsonline.gov.au

41. 41 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

42. 42 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

43. 43 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

44. 44 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

45. 45 Available at Resources CKD management in general practice 2012 Guidelines booklet www.kcat.org.au

46. 46 Available at Resources Guidelines for the assessment and management of Absolute Cardiovascular Disease Risk National Vascular Disease Prevention Alliance www.cvdcheck.org.au

47. 47 Available at www.kidney.org.au Resources CKD management guidelines for general practice

48. 48 Available along with more kidney health fact sheets at www.kidney.org.auwww.kidney.org.au > For Patients > Health Fact Sheets Resources CKD Patient fact sheets

49. 49 Free call information service for people living with / affected by kidney disease Resources Kidney Health Information Service

50. 50 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 To join the kidney community, email community@kidney.org.aucommunity@kidney.org.au

51. 51 Thankyou for participating in this workshop Please complete your evaluation form before leaving.