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General Practice Workshop

Early Detection & Management of Chronic Kidney Disease. A/Prof Craig Nelson Western Health. General Practice Workshop This workshop was conceived and developed by Kidney Health Australia’s Kidney Check Australia Taskforce

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General Practice Workshop

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  1. Early Detection & Management of Chronic Kidney Disease A/Prof Craig Nelson Western Health General Practice Workshop This workshop was conceived and developed by Kidney Health Australia’s Kidney Check Australia Taskforce with particular thanks to A/Prof Robyn Langham& A/Prof Timothy Mathew Version 03.14

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

  3. Learning Objectives

  4. 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.

  5. 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

  6. What is the role of the GP? • Usual setting for initial assessment and diagnosis is in the general practice setting • 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

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

  8. Growth in incidence rate of new treated ESKD and projections to 2020 AIHW, 2011. Projections of the incidence of treated End-Stage Kidney Disease in Australia, 2010-2020

  9. Costs of treating current and new ESKD cases to 2020 • The cost of treating ESKD from 2009 to 2020 is estimated to be around $12 billion to the Australian government • Kidney disease contributes approximately 15% of all hospitalisations in Australia Cass et al, 2010, economic impact ESKD in Australia, KHA

  10. Number of treated or non-treated cases by age group at ESKD onset 2003-2007 No dialysis / transplant dialysis / transplant Source: Linked ANZDATA Registry, AIHW National Mortality Database and National Death Index

  11. Australian CKD staging schema

  12. The CKD staging system for Australia To ascertain CKD Stage combine: • Kidney Function Stage (eGFR) (stage 1-5) • Kidney Damage (Albuminuria) • Clinical Diagnosis (underlying cause of CKD) E.g. CKD 3b with microalbuminuria secondary to diabetic kidney disease

  13. CKD staging system for Australia The current CKD staging system was introduced in 2012 because it: • Had a better correlation with progression • Factored in albuminuria • Resulted in quantification of risk for • CKD progression • CV events

  14. Relative Risk for general population cohorts with albumin-to creatinine ratio (ACR) Blue – normal ACR Green – microalbuminuria Red - macroalbuminuria Note log scale on Y axis for Hazard Ratio Adapted from Levey et al, 2010, Kidney International

  15. Using the CKD staging schema Normal Low Moderate High ‘CKD Management in General Practice’ booklet has colour-coded action plans for overall risk of • Progression of CKD • Cardiovascular events

  16. People at increased risk of CKD 1 in 3 Australian adults is at increased risk of CKD due to the above risk factors! RACGP Guidelines for preventive activities in general practice 8thedition; Chronic Kidney Disease Management in General Practice 2nd edition 2012

  17. Who should be tested for kidney disease? If an individual has multiple risk factors, follow the more frequent regime RACGP Guidelines for preventive activities in general practice 8thedition; Chronic Kidney Disease Management in General Practice 2nd edition 2012

  18. Kidney Health Check Blood pressure should be consistently below 140/90 mmHg Albumin / Creatinine Ratio (ACR) to check for albuminuria Creatinine & eGFR

  19. CKD screening should be undertaken as a part of every chronic disease & cardiovascular risk assessment

  20. What is GFR? GFR = Glomerular Filtration Rate • GFR is accepted as the best measure of kidney function • GFR can be estimated from serum creatinine using prediction equations • There is no direct way of measuring GFR • May fall substantially before serum creatinine is outside thenormal range

  21. CKD 1&2 Comparing eGFR and creatinine CKD 4 CKD 5 CKD 3 Serum creatinine 120 90 60 30 0 eGFRmL/min Actual Serum Creatinine Level Normal Serum Creatinine Level

  22. The significance of CKD staging using eGFR • Staging CKD using eGFR will assist with goals of management of CKD • Early detection and treatment may reduce the rate of progression of kidney failure and cardiovascular risk by 20 – 50%

  23. 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 (mayoverestimate 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 (egfenofibrate, trimethoprim)

  24. eGFR and drug dosing Where an eGFR (using CKD-EPI) 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

  25. Kidney Health Check CKD screening should be undertaken as a part of every chronic disease & cardiovascular risk assessment

  26. Current Urine Testing Recommendations Urine Tests for proteinuria • 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

  27. Albuminuria • Population studies show association between albuminuria and progressive kidney disease • Severity of albuminuria is predictive of outcome • Therapeutic intervention can delay progression of disease → most effective where there is significant albuminuria • Urine ACR accurately predicts renal and cardiovascular risks in population studies • Reduction in urine ACR predicts renoprotective benefit in intervention trials

  28. Urine Albumin / Creatinine Ratio (ACR) • An accurate ACR measurement is essential to fully stage CKD • Exhibits greater sensitivity than protein:creatinine ratio (PCR) • Initial ACR test should be repeated on a first void sample • Albuminuria is present if at least 2 out of 3 ACR tests are positive (including the initial test) • CKD is present if the albuminuria is persistent for at least 3 months • An ACR is now the preferred test for urine protein rather than dipsticks as sensitivity and specificity is more accurate

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

  30. CKD screening should be undertaken as a part of every chronic disease & cardiovascular risk assessment

  31. What’s new in CKD? Blood Pressure Targets

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

  33. Case study - Rita Past medical history • Overweight (BMI 29) • Mild intermittent asthma • Chronic low back pain • Mild hypertension • Current 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

  34. Case study - Rita

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

  36. Groups at increased risk of CKD Rita has 3 of the 8 Risk Factors

  37. 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 Or……damaged kidneys cause high blood pressure and high blood pressure damages kidneys

  38. Rita’s CKD risk factors: Diabetes • Patients who have diabetes develop CKD in up to 30% of cases.1 • 1% of adult Australians develop diabetes each year.2 1.Chadban et al. 2009 National Evidence Based Guideline for Diagnosis, Prevention and Management of Chronic Kidney Disease in Type 2 Diabetes, Diabetes Australia and the National Health and Medical Research Council (NHMRC), Canberra. 2. Barr et al. 2006, Int. DiabInstitute

  39. Rita’s CKD risk factor: Smoking Smokers with a 25-49 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) *CKD with eGFR <45mL/min/1.73m2 Hallan et al, Am J Kid Dis 2006

  40. 160 140 120 100 80 60 40 20 Rita’s CKD risk factors: Age > 60 Years Relationship of eGFR to age 2.50% Median 97.50% eGFR (mL/min/1.73m2) 20-24 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+ Age (years) Australasian Creatinine Consensus group. MJA 2007; 187(8): 459-463

  41. Other CKD risk factors: Obesity Being overweight (BMI 25-29 kg/m2 did not increase CKD risk, but all classes of obesity (BMI ≥ 30kg/m2) increased risk *CKD with eGFR <45mL/min/1.73m2 Hallan et al, Am J Kid Dis 2006

  42. Other CKD risk factors: Family history of Kidney Failure 23.9 22.9 20 14.6 14.4 Family history (%) of ESKD in incident dialysis patients 10 African-American women African-American men Caucasian women Caucasian men Freedman et al., JASN 1997

  43. Indigenous Australians starting treatment for ESKD • Other CKD risk factors: Aboriginal or Torres Strait Islander Origin Age group (years) Australian Institute of Health and Welfare, 2011

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

  45. Case study - Rita 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

  46. Case study - Rita

  47. Case study - Rita

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

  49. Case study - Rita To classify Rita as having CKD, her urine ACR & eGFR will need to be repeated and results must be consistent over 3 months or more • 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

  50. Repeating the urine ACR Factors other than CKD known 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)

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