General Practitioner WorkshopThis workshop was conceived and developed by the Kidney Check Australia Taskforce with particular thanks to A/Prof Robyn Langham & A/Prof Timothy Mathew

2013

Important Updates in the Early Detection & Management of

Chronic Kidney Disease

Learning Objectives

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.

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

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

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

Kidney disease in Australia

Australians aged ≥ 25 years

CKD staging is according to the CKD-EPI equation

AusDiab Report, 2001; White et al 2010; Jun 10 ABS data; 2011 ANZDATA report

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

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

Cum

ulati

ve C

ost (

$mill

ions

)

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

No dialysis / transplant

dialysis / transplant

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

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

2012 sees the introduction of a new CKD staging system because it:

Had a better correlation with progressionFactored in albuminuriaResulted in quantification of risk for

• CKD progression• CV events

The new CKD staging system for Australia

Staging of Chronic Kidney Disease

What’s new in CKD?

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 intoStage 3a (eGFR 45-59 mL/min/1.73m2)Stage 3b (eGFR 30-44 mL/min/1.73m2)

More accurately reflects risk stratification

Iseki et al, Kidney Int 2003;63:1468-1476

N= 106,000

Risk of ESKD related to baseline proteinuria (dipstick) over 18 year period

Blue – normal ACRGreen – microalbuminuriaRed - macroalbuminuria

Note log scale on Y axis for Hazard Ratio

Adapted from Levey et al, 2010, Kidney International

The new Australian CKD staging schema

Albuminuria Stage

GFR Stage

GFR (mL/min/1.73m2)

Normal(urine ACR mg/mmol)

Male: < 2.5Female: < 3.5

Microalbuminuria (urine ACR mg/mmol)

Male: 2.5-25Female: 3.5-35

Macroalbuminuria(urine ACR mg/mmol)

Male: > 25Female: > 35

1 ≥90 Not CKD unless haematuria, structural or

pathological abnormalities present2 60-89

3a 45-59

3b 30-44

4 15-29

5 <15 or on dialysis

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

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

People at increased risk of CKD

Eight major risk factors for CKD Diabetes

High blood pressureAge over 60 years

Smoking Obesity

Family history of kidney diseaseAboriginal 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!

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

Remember…

CKD screening should be undertaken as a part of a systematic chronic disease assessment

What is GFR?

• 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 >90mL/min/1.73m2 anddeclines 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

GFR = Glomerular Filtration Rate

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%

What’s new in CKD?

What Old New Rationale

eGFR & elderly

If aged >70 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

eGFR<60 mL/min/1.73m2 is associated with significantly increased risks of adverse clinical outcomes irrespective of age

eGFR – estimated Glomerular Filtration Rate

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

What is eGFR?

This is consistent with USA, UK & Australian clinical guidelines

Since 2005 it has been recommended that eGFR be automatically reported with every request for serum

creatinine in adults.

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

Comparing eGFR and creatinine

CKD 1&2

CKD 5CKD 4CKD 3

GFR mL/min120 90 60 30 0

Seru

m

crea

tinin

e

Normal Serum Creatinine Level

Actual Serum Creatinine Level

Limitations of eGFR

• 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)

Clinical situations where eGFR results may be unreliable and/or misleading:

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

Remember…

CKD screening should be undertaken as a part of a systematic chronic disease assessment

What’s new in CKD?

What Old New

Urine testing for proteinuria

Non-diabetes? dipstick? 24 hr urine protein? PCR? ACRDiabetesACR 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 specimenWhere a first void specimen is not possible or practical, a random spot urine

specimen for urine ACR is acceptable

Urine Tests for proteinuria

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

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

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

CKD screening should be undertaken as a part of a systematic chronic disease assessment

What’s new in CKD?

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

Case study

RitaRita is a new patient to your practice

• 63 years old• Accountant• History of mild asthma

• Overweight (BMI 29)• Mild intermittent asthma• Chronic low back pain• Mild hypertension• Smoker 25 pack year history

Past medical 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

Case study - Rita

Smoker: 20-25 cigarettes per day

Alcohol: 1-2 glasses of wine3-4 nights per week

Allergies: Nil known

Medications: Salbutamol 100mcg/doseas needed

Case study - Rita

Case study - Question

Groups at increased risk of CKD

Risk factors for CKD

High blood pressure SmokingAge over 60 yearsFamily history of kidney diseaseDiabetes ObesityAboriginal or Torres Strait Islander originEstablished cardiovascular disease

Rita has 4 of the 8 Risk Factors

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)

CKD risk factors: Obesity

Hallan et al, Am J Kid Dis 2006

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

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

Rela

tive

Risk

of C

KD*

(95%

CI)

Hallan et al, Am J Kid Dis 2006*CKD with eGFR <45mL/min/1.73m2

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

Parenchymal Renal Disease

Hypertension

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.

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

/1.7

3m2 )

2.50%Median97.50%

Relationship of eGFR to age

CKD risk factors: Age > 60 Years

Australasian Creatinine Consensus group. MJA 2007; 187(8): 459-463

Freedman et al., JASN 1997

African-Americanwomen

Fam

ily h

isto

ry (%

) of E

SKD

in

inci

dent

dia

lysi

s pa

tient

s

Caucasian women

African-American

men

Caucasian men

20

10

14.4 14.6

22.923.9

CKD risk factors: Family history

Age group (years)

Australian Institute of Health and Welfare, 2011

Indigenous Australians starting treatment for ESKD

CKD risk factors: Aboriginal or Torres Strait Islander Origin

Rita has 4 risk factors for CKD• Smoking• Age over 60• Family history• High blood pressure

Case study - Answer

Case study - Question

Who should be tested for kidney disease?Risk Factor Recommended Tests Frequency

Smoker

Urine ACReGFR

Blood PressureEvery 1-2 years*

Diabetes

Hypertension

Obesity

Established cardiovascular disease

Family history of CKD

Aboriginal or Torres Strait Islander origin aged over 30 years

If an individual has multiple risk factors, follow the more frequent regime

*yearly for people with diabetes or hypertension

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

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

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

Case study - Rita

Albuminuria StageGFR Stage GFR

(mL/min/1.73m2)

Normal(urine ACR mg/mmol)Male: < 2.5

Female: < 3.5

Microalbuminuria (urine ACR mg/mmol)

Male: 2.5-25Female: 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 RITA’S RESULTS

PUT HER HERE

3b 30-44

4 15-29

5 <15 or on dialysis

Case study - Rita

Not yet!

Case study - Question

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

Case study - Rita

Repeating the urine ACR

Factors other than CKD know to increase urine albumin excretion…

Urinary Tract InfectionHigh dietary protein intakeCongestive cardiac failureAcute febrile illnessHeavy exercise within 24 hoursMenstruation or vaginal dischargeDrugs (especially NSAIDs)

Rita comes back to see you three months later and you repeat her urine ACR, eGFR and

blood pressure…

Test 1st Visit This VisiteGFR 55 mL/min/1.73m2 52 mL/min/1.73m2

Urine ACR 5.7 mg/mmol 8.4 mg/mmolBP 155/95 mmHg 160/95 mmHg

Case study - Question

Albuminuria Stage

GFR StageGFR

(mL/min/1.73m2)

Normal(urine ACR mg/mmol)

Male: < 2.5Female: < 3.5

Microalbuminuria (urine ACR mg/mmol)

Male: 2.5-25Female: 3.5-35

Macroalbuminuria(urine ACR mg/mmol)

Male: > 25Female: > 35

1 ≥90 Not CKD unless haematuria, structural or

pathological abnormalities present2 60-89

3a 45-59 RITA FITS HERE

3b 30-44

4 15-29

5 <15 or on dialysis

You can now diagnose Rita as having CKD stage 3a with microalbuminuria

Case study - Rita

Orange Clinical Action PlaneGFR 30-59 mL/min/1.73m2 with microalbuminuria or eGFR 30-44 with normoalbuminuria

• 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

Goals of Management

Case study - Rita

Monitoring 3-6 monthly clinical review

Clinical assessment

Blood pressureWeight

Laboratory assessment

Urine ACRBiochemical profile including urea, creatinine,

electrolyteseGFRHbA1c (for people with diabetes)Fasting lipidsFull blood countCalcium and phosphateParathyroid hormone (6-12 monthly if eGFR <45

mL/min/1.73m2)

Orange Clinical Action PlaneGFR 30-59 mL/min/1.73m2 with microalbuminuria or eGFR 30-44 with normoalbuminuria

Case study - Rita

• Absolute Cardiovascular Risk assessment• Lifestyle modification• Blood pressure reduction• Lipid lowering treatments• Glycaemic control

It is also important to consider…

Orange Clinical Action PlaneGFR 30-59 mL/min/1.73m2 with microalbuminuria or eGFR 30-44 with normoalbuminuria

Case study - Rita

Case study - Question

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 www.cvdcheck.org.au

Australian Cardiovascular Risk Tool

• 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

Rita’s Cardiovascular Risk (www.cvdcheck.org.au)

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

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

160/95

Adequate BP management delays the progression of CKD

Bakris et al., Am J Kid Disease, 2000

If Rita’s blood pressure was consistently below target, the GFR loss per year would be

reduced by 80%

Lifestyle modificationLifestyle 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

Lifestyle modification effects on BP

* Dietary Approaches to Stop Hypertension

Modification Recommendation Approx SBP reduction

Weight reduction BMI 18-24.9 kg/m2 5-20 mmHg / 10kg lost

DASH* diet Fruit, vegies, low saturated and total fat 8-14 mmHg

Dietary salt restriction <100 mmol/day 2-8 mmHg

Physical activity Aerobic activity for 30mins most days 4-9 mmHg

Moderate alcohol consumption only 1-2 standard drinks/day 2-4 mmHg

Lipid lowering & glycaemic controlLipids•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

Case study - Question

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

Clinical tipWhen referring to a Nephrologist ensure patient has had a recent urine ACR, current blood chemistry and haematology and a urinary tract ultrasound.

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

Referral is NOT usually necessary if:• Stable eGFR ≥30 mL/min/1.73m2

• Urine ACR < 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. Don’t refer to Nephrologist if targets of therapy are achieved Spiral CT angiogram for hypertension is not recommended

without specialty advice

• 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

Orange Clinical Action PlaneGFR 30-59 mL/min/1.73m2 with microalbuminuria or eGFR 30-44 with normoalbuminuria

Case study – Action plan

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 modificationACE inhibitor or ARB

Albuminuria >50% reduction of baseline value ACE inhibitor or ARB

Cholesterol Total < 4.0 mmol/LLDL < 2.5 mmol/L

Dietary advicestatins

Blood glucose (for people with diabetes)

HbA1c <7.0% / 53 mmol/molLifestyle modificationOral hypoglycaemicInsulin

Case study - Question

CKD diagnosis, management & patient outcomes

• 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

The diagnosis of CKD brings with it the need to identify risk reduction measures both for kidney and

cardiovascular diseases

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

Remember…

New Edition!

now available at www.kcat.org.au

Further resources…

CKD Management in General Practice

2012 Guidelines booklet

Kidney Health Information Service

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

Join the Kidney Community…

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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

Urine tests

• 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

Albuminuria or Proteinuria? That is the question!!

Australasian Proteinuria Consensus statement, 2012