1. Detecting & Managing CKD Kidney Health Australia
2012
Important Updates in the Early Detection & Management of Chronic Kidney Disease
All Modules
General Practitioner Workshop
This workshop was conceived and developed by the Kidney Check Australia Taskforce
with particular thanks to A/Prof Robyn Langham & A/Prof Timothy Mathew
2013

2. Summarise the treatment options to delay progression of kidney disease
Learning Objectives
List the eight major risk factors for developing chronic kidney disease (CKD)
Explain and apply the changes in recommendations for the detection and staging of CKD focusing primarily on early detection and management
Summarise the treatment options to delay progression of kidney disease
Outline the importance of developing a system to identify patients at higher risk of CKD for a Kidney Health Check

3. 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.
Modules – 1, 2, 4, 7, 9, 10
This slide summarises the definition of CKD. It is in your handout – RNO-5044 (what you need to know about eGFR).
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.

4. CKD is a major public health problem
Detecting & Managing CKD Kidney Health Australia
2012
CKD is a major public health problem
1 in 9 Australian adults has CKD
You can lose up to 90% of your kidney function before experiencing any symptoms
Major risk factor for cardiovascular disease
Usual setting for initial assessment and diagnosis is in general practice
Common, harmful & treatable
Modules – 1, 2, 9

5. What is the role of the GP?
early detection and management of CKD
management of early CKD without referral to specialist
assessing and modifying
cardiovascular risk factors
treatment to slow or prevent
progression of kidney failure
avoiding nephrotoxic drugs
What is the role of the GP?
The early recognition of kidney disease and appropriate treatment has been shown to reduce the rate of progression to kidney failure by 20-50%. In some cases, all signs of kidney function deterioration will disappear with appropriate management.
GPs can play a critical role in helping to prevent or slow kidney failure, by:
early detection of CKD
instituting therapies which will slow or prevent progression to kidney failure
assessing and modifying cardiovascular risk factors
avoiding nephrotoxic drugs. [7]

6. Kidney disease in Australia
5 MILLION AT RISK
856,000
19,000
40,000
827,000
Stage 5 CKD
Stage 4 CKD
Stage 3 CKD
Hypertension Diabetes
Stage 1 – 2 CKD
Australians aged ≥ 25 years
CKD staging is according to the CKD-EPI equation
Modules – 1, 2, 4, 9
AusDiab Report, 2001; White et al 2010; Jun 10 ABS data; 2011 ANZDATA report

7. Growth in incidence rate of new treated ESKD and projections to 2020
AIHW, Projections of the incidence of treated End-Stage Kidney Disease in Australia,

8. Costs of treating current and new ESKD cases to 2020$0
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
$7,000
$8,000
$9,000
$10,000
$11,000
$12,000
$13,000
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
Cumulative Cost ($millions)
Cumulative present value costs, Model 1
Cumulative present value costs, Model 2
In 2009 dollars the cumulative cost of RRT between $11.3 billion and $12.3 billion by the end of 2020
Annual cost of RRT service provision between $1.58 billion and $1.86 in 2020 dollars
Cass et al, 2010, economic impact ESKD in Australia, KHA

9. No dialysis / transplant
Number of treated or non-treated cases by age group at ESKD onset
No dialysis / transplant
dialysis / transplant
Source: Linked ANZDATA Registry, AIHW National Mortality Database and National Death Index

10. What’s new in CKD? New CKD staging
New recommendations for testing for urine protein
New recommendations for eGFR and elderly people with CKD
New blood pressure targets
Modules – 1, 9

11. The new CKD staging system for Australia
2012 sees the introduction of a new CKD staging system because it:
Had a better correlation with progression
Factored in albuminuria
Resulted in quantification of risk for
CKD progression
CV events
Modules – 1, 2, 9

12. Staging of Chronic Kidney Disease
What’s new in CKD?
Staging of Chronic Kidney Disease
Old
New
Rationale
CKD staging system
Determined by eGFR
Determined by kidney function (eGFR) and the level of albuminuria in all stages of CKD
Recommended by all Australian and international guidelines and is a better indicator of overall risk
Stage 3 CKD
(eGFR mL/min/1.73m2)
Divided into
Stage 3a (eGFR mL/min/1.73m2)
Stage 3b (eGFR mL/min/1.73m2)
More accurately reflects risk stratification
All guidelines now recommend that the stages of CKD should be based on kidney function, kidney damage (albuminuria/proteinuria), and underlying diagnosis (e.g., Stage 2 CKD with microalbuminuria secondary to diabetic kidney disease)
Stage 3 CKD (eGFR mL/min/1.73m2) has been divided into Stage 3a (eGFR mL/min/1.73m2) and Stage 3b (eGFR mL/min/1.73m2) to more accurately reflect risk stratification.
eGFR is now calculated using the CKD-EPI formula as it improves risk stratification. This change in formula will make limited or no difference to your practice.

13. Risk of ESKD related to baseline proteinuria (dipstick) over 18 year period
Modules – 1, 4, 7
Iseki et al, Kidney Int 2003;63:

14. Note log scale on Y axis for Hazard Ratio
Blue – normal ACR
Green – microalbuminuria
Red - macroalbuminuria
Hazard ratios increase from GFR < 60 mL/min/1.73m2. This is the same across all conditions and for people with no protein (black/blue) microalbuminuria (green) and macroalbuminuria (red).
Note: theses graphs use a log scale.
Note log scale on Y axis for Hazard Ratio
Adapted from Levey et al, 2010, Kidney International

15. The new Australian CKD staging schema
Albuminuria Stage
GFR Stage
GFR
(mL/min/1.73m2)
Normal
(urine ACR mg/mmol)
Male: < 2.5
Female: < 3.5
Microalbuminuria
Male:
Female:
Macroalbuminuria
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

16. Using the new CKD staging schema
‘CKD Management in General Practice’ booklet has colour-coded action plans for overall risk of
Progression of CKD
Cardiovascular events
Normal
Low
Moderate
High
Modules – 1, 2, 4, 9

17. The new CKD staging system for Australia
CKD Stages are described by both
eGFR & Albuminuria status
Underlying cause of CKD
e.g Mrs S is a 55 year old lady with CKD 3b with microalbuminuria secondary to
type 2 Diabetes
Modules – 1, 2, 9

18. People at increased risk of CKD
Detecting & Managing CKD Kidney Health Australia
2012
People at increased risk of CKD
Eight major risk factors for CKD
Diabetes
High blood pressure
Age over 60 years
Smoking
Obesity
Family history of kidney disease
Aboriginal or Torres Strait Islander origin
Established cardiovascular disease
Modules – 1, 9
1 in 3 Australian adults is at increased risk of CKD due to the above risk factors!

19. How do we detect CKD? New Recommendations for CKD detection
Test Kidney Function
Blood test for eGFR (creatinine)
Test for Albuminuria
Urine test for albumin / creatinine ratio (ACR)
Test for Hypertension
Check patient’s blood pressure
This slide summarises the definition of CKD. It is in your handout – RNO-5044 (what you need to know about eGFR).
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.

20. Kidney Health Check Blood Test Urine Test BP Check Remember…
CKD screening should be undertaken as a part of a systematic chronic disease assessment

21. What is GFR? GFR = Glomerular Filtration Rate
GFR is accepted as the best measure of kidney function
May fall substantially before serum creatinine is outside the normal range
Normal GFR in healthy adults is >90mL/min/1.73m2 and declines with age
A GFR consistently <60mL/min/1.73m2 indicates CKD
A GFR of 60-90mL/min/1.73m2 should not be considered abnormal unless there is evidence of kidney damage.
A fall in GFR always precedes kidney failure
There is no direct way of measuring GFR
GFR can be estimated from serum creatinine using prediction equations
The eGFR is reported by all Australian pathology labs

22. How will eGFR help me and my patients?
Early detection & management of CKD:
slows progression
prevents complications
reduces cardiovascular risk
reduces morbidity & mortality
How will eGFR help me & my patients?
CKD is a very treatable condition. Early detection and timely appropriate management of CKD (especially with respect to blood pressure control) will substantially reduce kidney failure progression and cardiovascular risk by up to 50%.
eGFR has the potential to assist GPs to diagnose and treat CKD earlier, which will:
slow progression of kidney failure
prevent complications
reduce morbidity & mortality.
Early detection and treatment may reduce the rate of progression of kidney failure and cardiovascular risk by 20 – 50%

23. eGFR – estimated Glomerular Filtration Rate
What’s new in CKD?
eGFR – estimated Glomerular Filtration Rate
What
Old
New
Rationale
eGFR & elderly
If aged >70 years, stable eGFR between mL/min/1.73m2 may be ok for age in some cases
Age-related decision points are not recommended
eGFR<60 mL/min/1.73m2 is associated with significantly increased risks of adverse clinical outcomes irrespective of age
eGFR and Elderly Patients:
Previously - In people aged 70 years and older an eGFR from 45 to 59 mL/min/1.73m2, when stable over time and unaccompanied by other evidence of kidney damage, may be interpreted as consistent with a typical eGFR for this age and unlikely to be associated with CKD complications.
The 2010 Creatinine Consensus Working Group recommends against the use of age-related decision points in adults.
It is now known that an eGFR < 60 mL/min/1.73 m2 is very common in older people, but is nevertheless predictive of significantly increased risks of adverse clinical outcomes, and should not be considered physiological or age-appropriate.
CKD-EPI formula
the CKD Epidemiology Collaboration, established by the United States National Institute of Diabetes and Digestive and Kidney Diseases, developed a new CKD-EPI eGFR formula (Table 1) from a pooled data set involving 8254 participants in 10 studies5. Unlike the MDRD formula, which was developed from a population with CKD, the CKD-EPI formula was developed and validated in a large heterogeneous population with and without known CKD including subjects with diabetes, potential kidney donors and transplant recipients.
Validation of this formula in a separate external dataset of 3896 participants in 16 studies demonstrated that the CKD-EPI formula retained the precision and accuracy of the MDRD formula at GFR<60mL/min/1.73m2 with less bias, improved precision and greater accuracy at GFR >60 mL/min/1.73m2 6, 7. Subsequent epidemiologic evaluations in North American8 and Australian9 general population studies have shown that the CKD-EPI equation more appropriately categorises individuals with respect to long-term clinical risks of end-stage kidney disease, coronary heart disease, stroke and/or all-cause mortality than the MDRD equation. In particular, 1.9% of the AusDiab study population was reclassified as not having CKD and such reclassified individuals were predominantly younger women with a favourable cardiovascular risk profile and absence of significant albuminuria.
Changing from the MDRD formula to the CKD-EPI formula leads to higher eGFR values at normal or near-normal levels of kidney function, particularly in younger individuals (<60 years)9. In Caucasian men and women >70 and >75 years respectively, median eGFR estimates are lower for the CKD-EPI formula compared to the MDRD, although the magnitude of these differences is small10
It is now recommended that the CKD-EPI formula is used to calculate eGFR instead of the previously used MDRD formula
This will lead to improved risk stratification and will make little or no difference to your practice

24. What is eGFR?
Since 2005 it has been recommended that eGFR
be automatically reported with every request for serum creatinine in adults.
This is consistent with USA, UK & Australian clinical guidelines
CKD-EPI formula is now recommended because:
Thoroughly validated equation in adults
Superior to other equations and to 24-hour urine collections (when GFR <60 mL/min/1.73m2)
No requirement for additional measurements of BSA
See calculator at

25. Advantages of eGFR
eGFR is a more sensitive marker for mild/moderate CKD than creatinine alone
Serum creatinine concentration is an insensitive marker for detecting mild to moderate kidney failure
Patients may lose 50% or more of their kidney function before the serum creatinine rises above the upper limit of normal
Normal serum creatinine measurements do not exclude serious loss of kidney function

26. 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
Modules – 1, 9, 10
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.
Actual Serum Creatinine Level

27. Limitations of eGFR
Clinical situations where eGFR results may be unreliable and/or misleading:
acute changes in kidney function
people on dialysis
exceptional dietary intake (e.g. vegetarian diet, high protein diet, recent consumption of cooked meat, creatine supplements)
extremes of body size
diseases of skeletal muscle, paraplegia or amputees (may overestimate eGFR) or high muscle mass (may underestimate eGFR)
children under the age of 18 years
severe liver disease present
eGFR values above 90 mL/min/1.73m2
drugs interacting with creatinine excretion (eg fenofibrate, trimethoprim)

28. eGFR and drug dosing Recommendation:
Where an eGFR (using CKD-EPI or MDRD) is on hand it is clinically appropriate to use this to assist drug dosing decision making
Recommendation:
Dose reduction of some drugs is recommended for patients with reduced kidney function
Both eGFR (mL/min/1.73m2) and estimated CrCl (mL/min) provide an estimate of relative renal drug clearance
If using eGFR for drug dosing body size should be considered, in addition to referring to the approved Product Information
For drugs with a narrow therapeutic index, therapeutic drug monitoring or a valid marker of drug effect should be used to individualise dosing
for drug dosing in very large or very small people, it may be preferred to calculate an eGFR that is not normalised to 1.73m2
to revert to an uncorrected eGFR, the eGFR result from the CKD-EPI should be multiplied by the individual’s BSA divided by 1.73m2 to generate an eGFR in mL/min

29. Kidney Health Check Blood Test Urine Test BP Check Remember…
CKD screening should be undertaken as a part of a systematic chronic disease assessment

30. Urine Tests for proteinuria
What’s new in CKD?
Urine Tests for proteinuria
What
Old
New
Urine testing for proteinuria
Non-diabetes
? dipstick
? 24 hr urine protein
? PCR
? ACR
Diabetes
ACR recommended
Urine Albumin/ Creatinine ratio (ACR) recommended for everyone
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
Testing for Albuminuria: The 2011 Australasian Proteinuria Consensus Working Group recommends that the preferred method for the detection of albuminuria in both diabetic and non-diabetic patients is urinary albumin:creatinine ratio (ACR).
Proteins in the urine are mainly albumin, but also consist of low molecular weight immunoglobulin, lysozyme, insulin and beta-2 microglobulin.

31. Urine Albumin / Creatinine Ratio (ACR)
Exhibits greater sensitivity than protein:creatinine ratio (PCR)
An initial ACR test should be repeated on a first void sample
Albuminuria is present if at least two out of three ACR tests are positive (including the initial test). CKD is present if the albuminuria is persistent for at least three months
Dipsticks for protein in the urine are now no longer recommended for this purpose as their sensitivity and specificity is not optimal

32. Albuminuria
There is an association between albuminuria and progressive kidney disease in population studies
The severity of albuminuria is predictive of outcome
Therapeutic intervention can delay progression of disease and is most effective where there is significant albuminuria
Microalbuminuria is predictive of progressive renal disease in people with diabetes and Indigenous people.
Urine ACR accurately predicts renal and cardiovascular risks in population studies and reduction in urine ACR predicts renoprotective benefit in intervention trials

33. Approximate equivalents between urine ACR & other measure of albumin & protein

34. Kidney Health Check Blood Test Urine Test BP Check
CKD screening should be undertaken as a part of a systematic chronic disease assessment

35. Blood Pressure Targets
What’s new in CKD?
Blood Pressure Targets
What
Old
New
Blood Pressure Targets
People with >1g proteinuria/ day – BP target 125/75 mmHg
People with CKD (or other conditions) – BP target 130/80 mmHg
All other conditions – BP target 140/90 mmHg
People with CKD - should maintain a BP consistently below 140/90 mmHg
People with diabetes or microalbuminuria should maintain a BP consistently below 130/80 mmHg
Blood pressure targets:
There is now consensus that people with CKD should be treated with BP lowering drugs to maintain a BP that is consistently below 140/90 mmHg.
If diabetes or albuminuria is present (urine ACR >3.5 mg/mmol in females and >2.5 mg/mmol in males) a consistent BP below 130/80 mmHg should be achieved.
If an overlapping condition is present (e.g., CKD with concomitant diabetes), the lower blood pressure threshold applies..

36. Rita is a new patient to your practice
Case study Rita
Rita is a new patient to your practice
63 years old
Accountant
History of mild asthma

37. Case study - Rita Past medical history Overweight (BMI 29)
Mild intermittent asthma
Chronic low back pain
Mild hypertension
Smoker 25 pack year history
Family history
Maternal grandmother died of a heart attack in her 60’s but also had a history of ‘kidney problems’
Mother has type 2 diabetes
Father has angina and hypertension

38. Case study - Rita Smoker: 20-25 cigarettes per day Alcohol:
1-2 glasses of wine
3-4 nights per week
Allergies:
Nil known
Medications:
Salbutamol 100mcg/dose
as needed

39. Q1. Does Rita have an increased risk of CKD?
Case study - Question
Q1. Does Rita have an increased risk of CKD?

40. Groups at increased risk of CKD
Risk factors for CKD
High blood pressure
Smoking
Age over 60 years
Family history of kidney disease
Diabetes
Obesity
Aboriginal or Torres Strait Islander origin
Established cardiovascular disease
Rita has 4 of the 8 Risk Factors

41. CKD risk factors: Diabetes
Patients who have diabetes develop CKD in up to 25% of cases.
1% of adult Australians develop diabetes each year (Barr et al. 2006, Int. Diab Institute)

42. Detecting & Managing CKD Kidney Health Australia
CKD risk factors: Obesity
Being overweight (BMI kg/m2 did not increase CKD risk, but all classes of obesity (BMI ≥ 30kg/m2) increased risk
Modules – 1, 9
*CKD with eGFR <45mL/min/1.73m2
Hallan et al, Am J Kid Dis 2006

43. Detecting & Managing CKD Kidney Health Australia
CKD risk factor: Smoking
Smokers with a pack-year history had an increased risk of 42% compared with non-smokers and those with >50 pack years had 105% increased risk
Relative Risk of CKD* (95% CI)
Modules – 1, 9
*CKD with eGFR <45mL/min/1.73m2
Hallan et al, Am J Kid Dis 2006

44. Detecting & Managing CKD Kidney Health Australia
CKD risk factors: High blood pressure
High Blood pressure can damage the small blood vessels in the kidneys. The damaged vessels cannot filter waste products from the blood the way they should.
Parenchymal Renal Disease
Hypertension
Modules – 1, 9
Or……damaged kidneys cause high blood pressure and high blood pressure damages kidneys

45. CKD risk factors: Age > 60 Years
20-24
Age (years) 20 40 60 80
100
120
140
160
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
80-84
85-90
90+
eGFR (mL/min/1.73m2)
2.50%
Median
97.50%
Relationship of eGFR to age
Australasian Creatinine Consensus group. MJA 2007; 187(8):

46. CKD risk factors: Family history
African-American
women
Family history (%) of ESKD in incident dialysis patients
Caucasian
men 20 10
14.4
14.6
22.9
23.9
Modules – 1, 9
Freedman et al., JASN 1997

47. Indigenous Australians starting treatment for ESKD
CKD risk factors: Aboriginal or Torres Strait Islander Origin
Indigenous Australians starting treatment for ESKD
Modules – 1, 9
ATSI-G3-outlined
Age group (years)
Australian Institute of Health and Welfare, 2011

48. Case study - Answer Smoking Age over 60 Family history
Rita has 4 risk factors for CKD
Smoking
Age over 60
Family history
High blood pressure

49. Case study - Question
Q2. What would you do next?

50. 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 CKD
Aboriginal or Torres Strait Islander origin aged over 30 years
Modules – 1, 2, 7, 9
*yearly for people with diabetes or hypertension
If an individual has multiple risk factors, follow the more frequent regime

51. Case study - Rita Kidney Health Check Blood Test Urine Test BP Check
You determine that Rita should have a kidney health check every year
Creatinine & eGFR
Blood pressure should be consistently below 140/90 mmHg
Albumin / Creatinine Ratio (ACR) to check for albuminuria
Kidney Health Check
Blood Test
Urine Test
BP Check
If all 3 tests are normal then the kidneys are in good shape and need only be tested again as indicated by the applicable risk factors

52. Case study - Rita Rita’s Kidney Health Check Results Creatinine
118 µmol/L
eGFR
55 mL/min/1.73m2
Urine ACR
5.7 mg/mmol
Blood Pressure
155 / 95 mmHg

53. RITA’S RESULTS PUT HER HERE
Case study - Rita
Albuminuria Stage
GFR Stage
GFR (mL/min/1. 73m2)
Normal
(urine ACR mg/mmol)
Male: < 2.5
Female: < 3.5
Microalbuminuria
Male:
Female:
Macroalbuminuria
Male: > 25
Female: > 35 1
≥90
Not CKD unless haematuria, structural or pathological abnormalities present 2
60-89 3a
45-59
RITA’S RESULTS PUT HER HERE 3b
30-44 4
15-29 5
<15 or on dialysis

54. Not yet! Case study - Question
Q3. Do Rita’s Kidney Health Check results mean she has Chronic Kidney Disease?
Not yet!

55. Case study - Rita
To classify Rita as having CKD, her urine ACR & eGFR will need to be repeated
If the first ACR is a random spot, then repeat tests should ideally be first morning void specimens
CKD is present if at least 2 out of 3 ACR tests (including the initial test) in the next three months are positive
When initial eGFR is <60 mL/min/1.73m2 consider clinical situations where eGFR results may be unreliable/misleading
To confirm CKD, the repeat eGFR in 3 months time should also be below 60mL/min/1.73m2
Urine ACR accurately predicts renal and cardiovascular risks in population studies and reduction in urine ACR predicts reno-protective benefit in interaction trials

56. Repeating the urine ACR
Factors other than CKD know to increase urine albumin excretion…
Urinary Tract Infection
High dietary protein intake
Congestive cardiac failure
Acute febrile illness
Heavy exercise within 24 hours
Menstruation or vaginal discharge
Drugs (especially NSAIDs)

57. Case study - Question
Rita comes back to see you three months later and you repeat her urine ACR, eGFR and blood pressure…
Test
1st Visit
This Visit
eGFR
55 mL/min/1.73m2
52 mL/min/1.73m2
Urine ACR
5.7 mg/mmol
8.4 mg/mmol BP
155/95 mmHg
160/95 mmHg
Q4. What is your next step?

58. You can now diagnose Rita as having CKD stage 3a with microalbuminuria
Case study - Rita
You can now diagnose Rita as having CKD stage 3a with microalbuminuria
Albuminuria Stage
GFR Stage
GFR (mL/min/1.73m2)
Normal
(urine ACR mg/mmol)
Male: < 2.5
Female: < 3.5
Microalbuminuria
Male:
Female:
Macroalbuminuria
Male: > 25
Female: > 35 1
≥90
Not CKD unless haematuria, structural or pathological abnormalities present 2
60-89 3a
45-59
RITA FITS HERE 3b
30-44 4
15-29 5
<15 or on dialysis

59. Orange Clinical Action Plan
Case study - Rita
Orange Clinical Action Plan
eGFR mL/min/1.73m2 with microalbuminuria or eGFR with normoalbuminuria
Goals of Management
Investigations to exclude treatable disease
Reduce progression of disease
Reduce cardiovascular risk
Early detection & management of complications
Avoidance of nephrotoxic medications or volume depletion
Adjustment of medication doses to levels appropriate for kidney function
Appropriate referral to a Nephrologist

60. Orange Clinical Action Plan
Case study - Rita
Orange Clinical Action Plan
eGFR mL/min/1.73m2 with microalbuminuria or eGFR with normoalbuminuria
Monitoring
3-6 monthly clinical review
Clinical assessment
Blood pressure
Weight
Laboratory assessment
Urine ACR
Biochemical profile including urea, creatinine, electrolytes
eGFR
HbA1c (for people with diabetes)
Fasting lipids
Full blood count
Calcium and phosphate
Parathyroid hormone (6-12 monthly if eGFR <45 mL/min/1.73m2)

61. Orange Clinical Action Plan
Case study - Rita
Orange Clinical Action Plan
eGFR mL/min/1.73m2 with microalbuminuria or eGFR with normoalbuminuria
It is also important to consider…
Absolute Cardiovascular Risk assessment
Lifestyle modification
Blood pressure reduction
Lipid lowering treatments
Glycaemic control

62. Case study - Question
Q5. As Rita’s general practitioner, how do you reduce her risks of cardiovascular disease?

63. Cardiovascular risk reduction
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
CKD is one of the most potent known risk factors for cardiovascular disease
It is important to calculate Rita’s cardiovascular risk using the Australian cardiovascular risk tool at

64. Australian Cardiovascular Risk Tool
Rita’s Cardiovascular Risk (
The tool is approved by NH&MRC
If Rita had moderate to severe CKD defined as eGFR <45 mL/min/1.73m2 or macroalbuminuria (ACR >25mg/mmol men; >35mg/mmol women) she would be at the highest CVD risk and in this case the tool should not be applied

65. Blood pressure reduction
CKD can cause and aggravate hypertension and hypertension can contribute to the progression of CKD
Reducing blood pressure to 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
Rita has stage 3a CKD with microalbuminuria so her blood pressure needs to be maintained consistently below 130/80 mmHg

66. Blood pressure reduction
Clinical Tips
ACE inhibitors and ARBs can cause a reversible reduction in GFR when treatment initiated
If the reduction is less than 25% and stabilises within two months of starting therapy, the ACE inhibitor or ARB should be continued
If the reduction in GFR exceeds 25% below the baseline value, the ACE inhibitor or ARB should be ceased and consideration given to referral to a Nephrologist for bilateral renal artery stenosis

67. Adequate BP management delays the progression of CKD
Detecting & Managing CKD Kidney Health Australia
2012
Adequate BP management delays the progression of CKD
160/95
Modules – 1, 9
Maintaining BP within target very important
Target <130/80
This data demonstrates the impact hypertension can have on eGFR reduction
Margaret’s BP is 155/95mmHg, if left untreated or uncontrolled in 1 year her GFR could drop to 45mL/min/1.73m2
If Rita’s blood pressure was consistently below target, the GFR loss per year would be reduced by 80%
Bakris et al., Am J Kid Disease, 2000

68. Detecting & Managing CKD Kidney Health Australia
2012
Lifestyle modification
Lifestyle approaches are essential in reducing the overall cardiovascular risk - the key elements are:
‘SNAP’ (smoking, nutrition, alcohol, physical activity)
Stop smoking
A low calorie diet to reduce BMI
A low salt diet
Weight reduction
A reduction in alcohol intake
Physical activity

69. 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
Modules – 1, 2, 3, 7, 9
* Dietary Approaches to Stop Hypertension

70. Lipid lowering & glycaemic control
Lipids
Margaret’s lipids should be assessed
Lipid-lowering treatment should be considered for CVD risk reduction
Glycaemic control
Margaret’s glycaemic control should be assessed
For people with diabetes, blood glucose control significantly reduces the risk of developing CKD, and in those with CKD reduces the rate of progression

71. Q6. Should Rita be referred to a Nephrologist?
Case study - Question
Q6. Should Rita be referred to a Nephrologist?

72. Referral to a Nephrologist is recommended if:
eGFR <30mL/min/1.73m2
Persistent significant albuminuria (urine ACR ≥ 30mg/mmol)
Rapidly declining eGFR from a baseline of <60 mL/min/1.73m2 (a decline of >5mL/min/1.73m2 over a six-month period which is confirmed on at least three separate readings)
CKD and hypertension that is hard to get to target despite at least three anti-hypertensive agents
glomerular haematuria with macroalbuminuria
Anyone with an acute presentation and signs of acute nephritis (oliguria, haematuria, acute hypertension, and oedema) should be regarded as a medical emergency and referred without delay
Modules – 1, 2, 4, 7, 9
Appropriate referral is associated with:
reduced rates of progression to ESKD
decreased patient morbidity and mortality
decreased need for and duration of hospitalisation
increased likelihood of permanent dialysis access created prior to dialysis onset
increased likelihood of kidney transplantation
reduced initial costs of care following the commencement of dialysis
Clinical tip
When referring to a Nephrologist ensure patient has had a recent urine ACR, current blood chemistry and haematology and a urinary tract ultrasound.

73. Referral is NOT usually necessary if:
Stable eGFR ≥30 mL/min/1.73m2
Urine ACR < 30mg/mmol (with no haematuria)
Controlled blood pressure
The decision to refer or not must always be individualised and particularly in younger patients the indications for referral may be less stringent.
Useful Tips
Pay attention to CVD risk reduction
Consider discussing management issues with a Nephrologist in cases where uncertainty regarding referral exists.
Don’t refer to Nephrologist if targets of therapy are achieved
Spiral CT angiogram for hypertension is not recommended without specialty advice
Modules – 1, 4, 7, 9

74. Orange Clinical Action Plan
Case study – Action plan
Orange Clinical Action Plan
eGFR mL/min/1.73m2 with microalbuminuria or eGFR with normoalbuminuria
Follow the ‘Orange’ clinical action plan (found in ‘CKD management in General Practice’ 2nd ed)
Cardiovascular risk reduction
Blood Pressure should be consistently below 130/80 mmHg – use of ACE or ARB as appropriate
Lifestyle modification
Avoid nephrotoxic medications
Adjust dose of other medications to levels appropriate for her kidney function
No need for Nephrology referral at this stage
Continue to monitor 3-6 monthly

75. Treatment target for people with CKD
Parameter
Target
Treatment
Blood Pressure
≤ 140/90 mmHg or
≤ 130/80 mmHg if albuminuria is present
(ACR > 2.5 mg/mmol males; >3.5 mg/mmol females)
Lifestyle modification
ACE inhibitor or ARB
Albuminuria
>50% reduction of baseline value
Cholesterol
Total < 4.0 mmol/L
LDL < 2.5 mmol/L
Dietary advice
statins
Blood glucose (for people with diabetes)
HbA1c <7.0% / 53 mmol/mol
Oral hypoglycaemic
Insulin
Modules – 1, 9

76. Case study - Question
Q7. What difference does a CKD diagnosis make if I already manage my patients well?

77. CKD diagnosis, management & patient outcomes
The diagnosis of CKD brings with it the need to identify risk reduction measures both for kidney and cardiovascular diseases
Treatment targets and choices of therapy may differ with a CKD diagnosis
Early detection and management of CKD complications
Greater consideration of any prescribing - avoidance of nephrotoxic medications and ensuring dosages of other prescribed drugs are appropriate for the level of kidney function
Timely referral of CKD patients to a Nephrologist for more severe CKD or complications

78. Summary… CKD is common, harmful and treatable
Early detection is beneficial
Systematically identify patients at high risk of CKD (the 8 risk factors)
Perform a Kidney Health Check (urine ACR, eGFR, blood pressure) on at risk patients
CKD is present if 2 /3 urine ACR tests in 3 month period are positive
Repeat the eGFR if <60mL/min/1.73m2
Maintain blood pressure consistently below the relevant threshold
Refer to the CKD staging table and clinical action plans in ‘CKD Management in General Practice (2nd ed)’
GPs play a vital role in the management of CKD
Most CKD patients can be managed in general practice

79. Remember… New CKD staging
New recommendations for testing for urine protein
New recommendations for eGFR and elderly people with CKD
New blood pressure targets

80. CKD Management in General Practice now available at www.kcat.org.au
Further resources…
CKD Management in General Practice
2012 Guidelines booklet
New Edition!
now available at
All modules

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

82. 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,

83. Any Questions?
All modules

84. Use of eGFR in different ethnic populations -recommendations
The CKD-EPI formula is a useful tool to estimate GFR in all people, including various ethnic populations
The CKD-EPI formula has been validated as a tool to estimate GFR in some non-Caucasian populations, including South-East Asian, African, Indian and Chinese individuals living in Western countries
The different methods to estimate GFR from serum creatinine concentration have not been validated in Indigenous Australians, although these studies are currently underway
Australasian Creatinine Consensus statement, 2012

85. Albuminuria or Proteinuria? That is the question!!
Urine tests
Albuminuria or Proteinuria? That is the question!!
The term albuminuria includes increased urinary excretion of albumin and increased urinary excretion of other proteins
It is very rare for a patient 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
Australasian Proteinuria Consensus statement, 2012