Early Renal Impairment

1
Important Updates in the Early Detection
Management of Chronic Kidney Disease
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
Learning Objectives
3
What is CKD?

• Chronic kidney disease is defined as

Glomerular Filtration Rate (GFR) lt 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.

4
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

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

6
Kidney disease in Australia 
Australians aged 25 years
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, 2011. Projections of the incidence of
treated End-Stage Kidney Disease in Australia,
2010-2020
8
Costs of treating current and new ESKD cases to
2020
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
Number of treated or non-treated cases by age
group at ESKD onset 2003-2007
Source Linked ANZDATA Registry, AIHW National
Mortality Database and National Death Index
10
Whats 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

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

12
Whats 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 Stage 3 CKD (eGFR 30-59 mL/min/1.73m2) Divided into Stage 3a (eGFR 45-59 mL/min/1.73m2) Stage 3b (eGFR 30-44 mL/min/1.73m2) More accurately reflects risk stratification
13
Risk of ESKD related to baseline proteinuria
(dipstick) over 18 year period
N 106,000
Iseki et al, Kidney Int 2003631468-1476
14
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
The new Australian CKD staging schema
Albuminuria Stage Albuminuria Stage Albuminuria Stage
GFR Stage GFR (mL/min/1.73m2) Normal (urine ACR mg/mmol) Male lt 2.5 Female lt 3.5 Microalbuminuria (urine ACR mg/mmol) Male 2.5-25 Female 3.5-35 Macroalbuminuria (urine ACR mg/mmol) Male gt 25 Female gt 35
1 90 Not CKD unless haematuria, structural or pathological abnormalities present
2 60-89 Not CKD unless haematuria, structural or pathological abnormalities present
3a 45-59
3b 30-44
4 15-29
5 lt15 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

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
18
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
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 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 patients blood pressure

20
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 thenormal range
• Normal GFR in healthy adults is gt90mL/min/1.73m2
  anddeclines with age
• A GFR consistently lt60mL/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

Early detection and treatment may reduce the rate
of progression of kidney failure and
cardiovascular risk by 20 50
23
Whats new in CKD?
eGFR estimated Glomerular Filtration Rate
What Old New Rationale
eGFR elderly If aged gt70 years, stable eGFR between 45-59 mL/min/1.73m2 may be ok for age in some cases Age-related decision points are not recommended eGFRlt60 mL/min/1.73m2 is associated with significantly increased risks of adverse clinical outcomes irrespective of age
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?

• This is consistent with USA, UK Australian
  clinical guidelines

25
Advantages of eGFR

• eGFR is a more sensitive marker for mild/moderate
  CKD than creatinine alone
• Serum creatinine concentration is an insensitive
  marker fordetecting mild to moderate kidney
  failure
• Patients may lose 50 or more of their kidney
  function beforethe serum creatinine rises above
  the upper limit of normal
• Normal serum creatinine measurements do not
  excludeserious loss of kidney function

26
Comparing eGFR and creatinine
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

• 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

29
Remember
CKD screening should be undertaken as a part of a
systematic chronic disease assessment
30
Whats 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
31
Urine Albumin / Creatinine Ratio (ACR)

• Exhibits greater sensitivity than
  proteincreatinine 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
CKD screening should be undertaken as a part of a
systematic chronic disease assessment
35
Whats new in CKD?
Blood Pressure Targets
What Old New
Blood Pressure Targets People with gt1g 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
36
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 60s 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
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
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 lt45mL/min/1.73m2
Hallan et al, Am J Kid Dis 2006
43
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 gt50 pack years had 105 increased
risk
Relative Risk of CKD (95 CI)
CKD with eGFR lt45mL/min/1.73m2
Hallan et al, Am J Kid Dis 2006
44
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.
Ordamaged kidneys cause high blood pressure and
high blood pressure damages kidneys
45
CKD risk factors Age gt 60 Years
Australasian Creatinine Consensus group. MJA
2007 187(8) 459-463
46
CKD risk factors Family history
Freedman et al., JASN 1997
47
Indigenous Australians starting treatment for ESKD
CKD risk factors Aboriginal or Torres Strait
Islander Origin
Age group (years)
Australian Institute of Health and Welfare, 2011
48
Case study - Answer

• 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 Urine ACR eGFR Blood Pressure Every 1-2 years
Hypertension Urine ACR eGFR Blood Pressure Every 1-2 years
Obesity Urine ACR eGFR Blood Pressure Every 1-2 years
Established cardiovascular disease Urine ACR eGFR Blood Pressure Every 1-2 years
Family history of CKD Urine ACR eGFR Blood Pressure Every 1-2 years
Aboriginal or Torres Strait Islander origin aged over 30 years Urine ACR eGFR Blood Pressure Every 1-2 years
yearly for people with diabetes or hypertension
If an individual has multiple risk factors,
follow the more frequent regime
51
Case study - Rita

• You determine that Rita should have a kidney
  health check every year

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
Ritas Kidney Health Check Results Ritas 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
Case study - Rita
Albuminuria Stage Albuminuria Stage Albuminuria Stage
GFR Stage GFR (mL/min/1.73m2) Normal (urine ACR mg/mmol) Male lt 2.5 Female lt 3.5 Microalbuminuria (urine ACR mg/mmol) Male 2.5-25 Female 3.5-35 Macroalbuminuria (urine ACR mg/mmol) Male gt 25 Female gt 35
1 90 Not CKD unless haematuria, structural or pathological abnormalities present
2 60-89 Not CKD unless haematuria, structural or pathological abnormalities present
3a 45-59 RITAS RESULTS PUT HER HERE
3b 30-44
4 15-29
5 lt15 or on dialysis
54
Case study - Question

• Q3. Do Ritas 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 lt60 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

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
Case study - Rita
You can now diagnose Rita as having CKD stage 3a
with microalbuminuria
Albuminuria Stage Albuminuria Stage Albuminuria Stage
GFR Stage GFR (mL/min/1.73m2) Normal (urine ACR mg/mmol) Male lt 2.5 Female lt 3.5 Microalbuminuria (urine ACR mg/mmol) Male 2.5-25 Female 3.5-35 Macroalbuminuria (urine ACR mg/mmol) Male gt 25 Female gt 35
1 90 Not CKD unless haematuria, structural or pathological abnormalities present
2 60-89 Not CKD unless haematuria, structural or pathological abnormalities present
3a 45-59 RITA FITS HERE
3b 30-44
4 15-29
5 lt15 or on dialysis
59
Case study - Rita

• Orange Clinical Action Plan

eGFR 30-59 mL/min/1.73m2 with microalbuminuria or
eGFR 30-44 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
Case study - Rita

• Orange Clinical Action Plan

eGFR 30-59 mL/min/1.73m2 with microalbuminuria or
eGFR 30-44 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 lt45 mL/min/1.73m2)
61
Case study - Rita

• Orange Clinical Action Plan

eGFR 30-59 mL/min/1.73m2 with microalbuminuria or
eGFR 30-44 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 Ritas 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 Ritas
  cardiovascular risk using the Australian
  cardiovascular risk tool at www.cvdcheck.org.au

64
Australian Cardiovascular Risk Tool
Ritas Cardiovascular Risk (www.cvdcheck.org.au)

• The tool is approved by NHMRC
• If Rita had moderate to severe CKD defined as
  eGFR lt45 mL/min/1.73m2 or macroalbuminuria (ACR
  gt25mg/mmol men gt35mg/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
If Ritas 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
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
Modification Recommendation Approx SBP reduction
Weight reduction BMI 18-24.9 kg/m2 5-20 mmHg / 10kg lost
Dietary salt restriction lt100 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
70
Lipid lowering glycaemic control

• Lipids
• Margarets lipids should be assessed
• Lipid-lowering treatment should be considered for
  CVD risk reduction
• Glycaemic control
• Margarets 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
Case study - Question
Q6. Should Rita be referred to a Nephrologist?
72
Referral to a Nephrologist is recommended if

• eGFR lt30mL/min/1.73m2
• Persistent significant albuminuria (urine ACR
  30mg/mmol)
• Rapidly declining eGFR from a baseline of lt60
  mL/min/1.73m2 (a decline of gt5mL/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

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 lt 30mg/mmol (with no haematuria)
• Controlled blood pressure

• Useful Tips
• Pay attention to CVD risk reduction
• Consider discussing management issues with a
  Nephrologist in cases where uncertainty regarding
  referral exists.
• Dont refer to Nephrologist if targets of therapy
  are achieved
• Spiral CT angiogram for hypertension is not
  recommended without specialty advice

74
Case study Action plan
Orange Clinical Action Plan
eGFR 30-59 mL/min/1.73m2 with microalbuminuria or
eGFR 30-44 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 gt 2.5 mg/mmol males gt3.5 mg/mmol females) Lifestyle modification ACE inhibitor or ARB
Albuminuria gt50 reduction of baseline value ACE inhibitor or ARB
Cholesterol Total lt 4.0 mmol/L LDL lt 2.5 mmol/L Dietary advice statins
Blood glucose (for people with diabetes) HbA1c lt7.0 / 53 mmol/mol Lifestyle modification Oral hypoglycaemic Insulin
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 lt60mL/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
80
Further resources
CKD Management in General Practice 2012
Guidelines booklet

• New Edition!
• now available at www.kcat.org.au

81
Kidney Health Information Service

• Free call information service for people living
  with / affected by kidney disease

82
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To join the kidney community, email
community_at_kidney.org.au
83
Any Questions?
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
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