Connecting Chronic Kidney Disease: the link with Diabetes

Transcription

1 Connecting Chronic Kidney Disease: the link with Diabetes Primary Care Education Workshop This module was conceived and developed by PEAK* 1 Presented by: V0617

2 Collaborators *This Education was conceived and developed by the Primary Care Education Advisory Committee for KHA (PEAK) KHA s Primary Care Education program is proudly supported by unrestricted educational grants from: 2

3 Learning outcomes At the end of this workshop participants will be able to: State the major risk factors for developing chronic kidney disease (CKD) Determine the stage of chronic kidney disease (CKD) through accurate interpretation of kidney function test results Outline the adverse outcomes of a combined diabetes and CKD diagnosis (Diabetic Kidney Disease, DKD) Explore the nurse's role in early detection, reducing the modifiable risk factors and management of DKD Develop a system to screen at risk patients that includes CKD testing and management 3

4 What is CKD? Chronic kidney disease is defined as: Glomerular Filtration Rate (GFR) < 60 ml/min/1.73m 2 for 3 months with or without evidence of kidney damage. OR Evidence of kidney damage (with or without decreased GFR) for 3 months: albuminuria haematuria after exclusion of urological causes pathological abnormalities anatomical abnormalities 4 Chronic Kidney Disease (CKD) Management in General Practice, 3 rd edition. Kidney Health Australia: Melbourne, 2015

5 A snapshot of kidney disease in Australia It s common 1 in 10 adults has at least one clinical sign of kidney disease 1. It s harmful In the top 10 causes of death 2. Kills more people each year than breast cancer, prostate cancer and road deaths. It s manageable If detected early and treated properly the decline in kidney function can be significantly reduced. 5 1 Australian Health Survey, Australian Bureau of Statistics, Causes of Death, 2012

6 Australians living with signs of CKD > 12% of population with signs of CKD 8-11% of population with signs of CKD < 7% of population with signs of CKD No data available 6 State of the Nation Report 2016, Kidney Health Australia

7 General chemistry results Combine egfr, albuminuria and underlying diagnosis to specify CKD stage GENERAL CHEMISTRY Sodium 144 mmol/l ( ) Pot. 4.3 mmol/l ( ) Chlor. 106 mmol/l (98-109) Bicarb. 26 mmol/l (20-32) Urea 6.5 mmol ( ) Creat. 55 µmol/l (40-85) egfr 84 ml/min/1.73m 2 Urate 0.35 mmol/l ( ) *Gluc 9.5 mmol/l (Random: ; Fasting: ) Albumin 40 g/l (35-50) 7

8 Staging CKD Combine egfr stage, albuminuria stage and underlying diagnosis to specify CKD stage e.g. stage 3b CKD with microalbuminuria secondary to diabetic kidney disease Albuminuria Stage GFR Stage GFR ml/min/1. 73m 2 Normal urine ACR mg/mmol Male: < 2.5 Female: < 3.5 Microalbuminuria urine ACR mg/mmol Male: Female: Macroalbuminuria urine ACR mg/mmol Male: > 25 Female: > Not CKD unless haematuria, structural or pathological abnormalities present 3a b X 5 <15 or on dialysis Colour-coded Clinical Action Plans in handbook and on CKD-Go! App 8 Chronic Kidney Disease (CKD) Management in General Practice, 3 rd edition. Kidney Health Australia: Melbourne, 2015

9 Connecting CKD and diabetes Every second patient* you see with Type 2 diabetes WILL have CKD A patient with diabetes has CKD if they have 1 or more: Persistent microalbuminuria or proteinuria An egfr < 60mL/min/1.73m 2 and/or Haematuria after exclusion of urological causes or structural abnormalities 9 *NEFRON Study 2007

10 Connecting CKD and diabetes Health care burden associated with DKD and DM- ESKD in Australia is significant and expanding Diabetes is the leading cause of incident end-stage kidney disease (DM-ESKD) The growing prevalence of T2DM in Australia, indicates the prevalence of DKD will continue to grow substantially The first priority in screening for DKD should be the detection of microalbuminuria Pharmacological intervention in DKD is stabilising the incidence of ESKD at the population level 10

11 Connecting CKD and diabetes Monitoring for kidney disease must be made a high priority for all people with type 2 diabetes Concerted effort needs to made to ensure that glucose control is optimised, blood pressure and lipids targets are met Opportunities for prevention across the entire disease continuum 11 Sarah White and Steve Chadban, Kidney Research Node Royal Prince Alfred Hospital and Charles Perkins Centre, University of Sydney April

12 An egfr less than 60mL/min/1.73m 2 indicates High risk of heart attack or stroke Decreased survival after a heart attack More common adverse drug reactions Slow wound healing Difficulty in achieving BP goals Difficult fluid control i.e. ankle swelling, fluid retention 12 *NEFRON Study 2007

13 An egfr less than 60mL/min/1.73m 2 indicates Less than 1 in every 20 patients with diabetes and CKD will live long enough to require dialysis or transplantation* Increased likelihood of fractures with falls Increased likelihood of hypoglycaemia Increased likelihood of hospitalisation in next 12 months Increased likelihood of heart failure 13 *NEFRON Study 2007

14 14 Diabetes affect on the body

15 Number of patients per year Diabetes progression to dialysis 1200 In the last 10 years there has been a 60% increase in the number of people with type 2 diabetes starting dialysis New patients with ESKD due to diabetes starting on dialysis (Australia ) Type 2 Type ANZDATA, Annual Reports. Available at

16 Rate pmp Diabetes and dialysis Diabetes is the cause of kidney failure that is largely driving the increase in dialysis patients in Australia Diabetes Gn BP Misc Uncertain PCK Reflux Analg Nx ANZDATA Registry

17 Diabetic Kidney Disease (DKD) Diabetes causes damage to the kidneys; called Diabetic Kidney Disease (DKD) or diabetic nephropathy Worsens other complications from diabetes such as nerve and eye damage Increases the risk of cardiovascular disease Usually has no symptoms until it is well advanced 17

18 Diabetic Kidney Disease (DKD) most frequent cause of kidney failure worldwide associated with increased morbidity and mortality at all stages of CKD early detection and comprehensive management is associated with improved outcomes CKD management overlaps entirely with diabetes management and cardiovascular risk reduction 18

19 Diabetic Kidney Disease (DKD) 20-40% of patients with Type 2 diabetes develop nephropathy, which classically occurs in two stages: Early nephropathy: microalbuminuria and normal to high GFR Overt nephropathy: macroalbuminuria and progressive decline in GFR 19

20 Connecting CKD and diabetes The presence of diabetes worsens the outcomes in all stages of CKD: CVD outcomes Dialysis survival Post-transplant survival 20

21 Events/100 pt/yrs CKD and diabetes, the connection Diabetes multiplies the morbidity/mortality event rate in CKD US Medicare (5% sample); Age >65, no RRT, followed 2yrs. n =1,091, D- CKD- 80% D+ CKD- 17% D- CKD+ 2.2% D+ CKD+ 1.6% ASVD CHF RRT Death ASVD, atherosclerotic vascular disease; CHF, chronic heart failure; RRT, renal replacement therapy 21 Foley et al. JASN 16: , 2005

22 Case study - Peter Background 62 years old Caucasian male Works full-time in business management Today Peter presents at your general practice with an acute cough with yellow sputum He has previously been seen at your practice when he accompanied his wife for an annual flu vaccination 22

23 History Smoker: Alcohol: Nutrition: Medical conditions: Medications: 1 packet per day for 40 years (40 pack-year history) 7-10 drinks per week Follows a diabetic diet Type 2 diabetes, diagnosed 12 months ago after presenting with thirst No regular medications, takes occasional NSAIDS for back pain 23

24 Case study - Peter Today s visit Test Blood pressure Weight Result 160/90 mmhg 102 kg BMI 31 kg/m 2 Waist circumference Chest findings 110 cm Consistent with bronchitis - no clinical signs of COPD 24

25 Case study Question Q1: Is Peter at increased risk of kidney disease? If so, why? Today s visit Peter s GP found some of his results and history concerning. The GP has asked you to review Peter s case further, particularly his potential risk for kidney disease. 25

26 Risk factors for kidney disease Diabetes Hypertension Established cardiovascular disease Family history of kidney failure Obesity (BMI >30kg/m 2 ) Smoker Aboriginal or Torres Strait Islander origin History or acute kidney injury Age over 60 years Peter has 5 of the risk factors for CKD 1 in 3 Australian adults is at increased risk of CKD due to these risk factors 26 RACGP Guidelines for preventive activities in general practice 8 th edition; Chronic Kidney Disease (CKD) Management in General Practice, 3 rd edition. Kidney Health Australia: Melbourne, 2015

27 Case study Question Q1a: What does Peter s diabetes mean for his CKD risk? % of patients with Type 2 diabetes develop nephropathy, which classically* occurs in 2 stages: Early nephropathy - microalbuminuria and normal-high GFR Overt nephropathy - macroalbuminuria and progressive decline in GFR * Recent data shows that 33% individuals with diabetes with egfr <60ml/min/1.73m 2 do not have albuminuria, and for these subjects, prognosis is similar to those with albuminuria 1,2 1. Tapp RJ, Shaw J, Chadban SJ et al. Am J Kidney Dis 2004; 44: Agarwal et al, NDT 2011

28 Classical stages of diabetic kidney disease* *Those with Type 2 diabetes may have overt nephropathy at presentation GFR normal normal Albuminuria Duration of Diabetes (years)

29 Further reading KinD Report

30 Case study Question Q1b: Peter has hypertension. What does this mean for his CKD risk? Hypertension is extremely common among those with type 2 diabetes, particularly those with DKD Among those with diabetes (and without), those with hypertension are 5-8 times as likely to have albuminuria Achieving BP control is one of the most effective ways to delay the progression of kidney disease 30

31 Hypertension Adequate BP management delays the progression of CKD (reduces the GFR drop/year) 31 If Peter s BP was consistently below target, his GFR loss per year would be reduced by 71% 160/90mmHg Bakris et al., Am J Kid Disease, 2000

32 Case study Question Q1c: Peter is obese. What impact does his weight have on his risk of CKD? Overweight (BMI ) and obese (BMI >30) people are 40% and 80% more likely to develop CKD compared to normal weight individuals 1 Central obesity appears to be more important than generalised Obesity contributes to the development of albuminuria and proteinuria Obesity leads to greater difficulty in achieving glycaemic control and BP control 32 1 Wang Y et al. Association between obesity and kidney disease: a systematic review and meta-analysis. Kidney Int. 2008;73:19-33.

33 Case study Question Q1d: How does smoking increase Peter s risk of CKD? Among individuals with diabetes, those who smoke are more likely to get albuminuria and among those with diabetic kidney disease, smoking accelerates progression to failure 1,2 Even among the normal Australian population, smoking has been associated with kidney damage 3 33 [1] Gambaro et al. Diabetes Nutr Metab 2001;14:337. [2] Orth & Hallan. Clin J Am Soc Nephrol [3] Briganti et al. Am J Kidney Dis 2002;40:704.

34 Case study Question Q1e: Does Peter s occasional NSAID use increase his risk of CKD? Probably not Chronic use of NSAIDs have not been proven to lead to CKD in humans NSAID ingestion can aggravate underlying kidney disease and hypertension and risk of vascular events NSAIDs should be avoided in this setting 34

35 Case study Question Q1f: Will Peter s chest infection contribute to his likelihood of CKD? No Chest infection by itself has no relationship to CKD Recurrent chest infections are more common in smokers With his history of smoking Peter is highly likely to develop COPD in the future 35

36 CVD risk Australian Absolute Cardiovascular Disease Risk Calculator 36 **Peter is at increased risk of kidney disease and therefore also at risk of having a cardiovascular event.

37 CVD risk anyone with egfr < 45 ml/min/1.73m 2 or persistent proteinuria Diabetes and microalbuminuria Diabetes and age > 60 years Established cardiovascular disease Familial hypercholesterolemia or total cholesterol above 7.5 Severe hypertension Systolic 180 mmhg or greater Diastolic 110 mmhg or greater 37 is already at the highest risk of a cardiovascular event, therefore the calculator should not be used Guidelines for the management of Absolute cardiovascular disease risk: National Vascular Prevention Alliance.

38 Cardiovascular risk reduction in CKD CKD is one of the most potent known risk factors for cardiovascular disease It is essential to clinically determine the risk of CKD before using the Australian absolute cardiovascular risk tool ( ) to accurately calculate cardiovascular risk 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 38 Chronic Kidney Disease (CKD) Management in General Practice, 3rd edition. Kidney Health Australia: Melbourne, 2015

39 Resources Guidelines for the assessment and management of Absolute Cardiovascular Disease Risk National Vascular Disease Prevention Alliance Available at 39

40 Checking for kidney damage Q2: What test results would you use as evidence of kidney damage? Peter is at increased risk of kidney disease and you decide to test him for evidence of kidney damage.? urine dipstick for blood and protein? spot urine albumin/creatinine ratio (ACR)? 24 hour urine protein? serum creatinine? egfr? renal ultrasound (kidney outline and size) 40

41 Checking for kidney damage? urine dipstick for blood and protein spot urine albumin/creatinine ratio (ACR)? 24 hour urine protein serum creatinine egfr? renal ultrasound (kidney outline and size) 41

42 Urine albumin /creatinine ratio (ACR) The preferred urine test in all diabetics is to look for microalbuminuria This is best tested by a urine albumin:creatinine ratio (ACR) Preferably 1st morning void but a random sample can also be used ACR result Test results range Recommended follow -up Normal Females <3.5 mg/mmol Males <2.5 mg/mmol Re-test annually 42 Microalbuminuria Macroalbuminuria (also called proteinuria) Females mg/mmol Males mg/mmol Females >35 mg/mmol Males >25 mg/mmol Repeat 2 times over 3 months Confirm microalbuminuria if 2 out of 3 tests are positive Do a protein:creatinine ratio (PCR) or 24 hour urine protein (to quantify protein excretion) NHMRC Guidelines 2009

43 Glomerular filtration rate Glomerular filtration rate (GFR) best measure of kidney function Can be estimated (egfr) from serum creatinine egfr automatically provided by pathology laboratories when a creatinine is ordered (for adults over 18 yrs) Reported as an actual numerical value or > 90mL/min/1.73m 2 egfr is accurate at values <60 ml/min/1.73m 2 Tends to underestimate GFR in those with diabetes with true GFR > 60 ml/min/1.73m 2 Creatinine alone will commonly under-estimate the degree of reduction in kidney function, particularly in small elderly women 43 Australasian Proteinuria Consensus Group, 2012 Chudleigh et al, Diabetes Care 2007;30:300-5.

44 Serum creatinine Comparing creatinine and egfr CKD 3bCKD 3a CKD 1 & 2 CKD 4 CKD Dialysis GFR ml/min Albuminuria 44 Normal Serum Creatinine level Actual Serum Creatinine level

45 Screening for CKD Indications for assessment* Diabetes Hypertension Established cardiovascular disease ** Family history of kidney failure Obesity (BMI 30 kg/m 2 ) Smoker Aboriginal or Torres Strait Islander origin aged 30 years History of acute kidney injury Recommended assessments Urine ACR, egfr, blood pressure If urine ACR positive repeat twice over 3 months (preferably first morning void) If egfr < 60mL/min/1.73m 2 repeat within 7 days See recommendations in booklet Frequency Every 1-2 *Whilst being aged 60 years of age or over is considered to be a risk factor for CKD, in the absence of other risk factors it is not necessary to routinely assess these individuals for kidney disease. **Established cardiovascular disease is defined as a previous diagnosis of coronary heart disease, cerebrovascular disease or peripheral vascular disease. Annually for individuals with diabetes or hypertension. Refer to booklet for more details regarding recommendations for testing in Aboriginal and Torres Strait Islander peoples. years 1 in 3 Australia n adults is at increased risk of CKD due to these risk factors 45 Chronic Kidney Disease (CKD) Management in General Practice, 3rd edition. Kidney Health Australia: Melbourne, 2015

46 Kidney Health Check Kidney Health Check Blood Test Urine Test BP Check egfr calculated from serum creatinine Albumin / Creatinine Ratio (ACR) check for albuminuria Blood pressure maintain consistently below BP goal CKD screening should be undertaken as a part of every chronic disease & cardiovascular risk assessment 46 Chronic Kidney Disease (CKD) Management in General Practice, 3 rd edition. Kidney Health Australia: Melbourne, 2015

47 Case study - Peter You identify Peter as being at increased risk for CKD and request he be recalled for further tests. Peter's test results show the following: Test Creatinine Result 135 µmol/l egfr 46 ml/min/1.73m 2 Urine ACR HbA1c Blood pressure 44 mg/mmol (macroalbuminuria) 9.6% / 81 mmol/mol 160/90 mmhg 47

48 Case study - Peter Q3: What can be done to improve Peter s control of his diabetes? Good glycaemic control slows progression of kidney failure* Prescribe exercise and diet 44% of patients are on a sulphonylurea Metformin okay to use in reduced doses when egfr is between 30 and 60 ml/min - avoid use if GFR below 30 ml/min, due to risk of acidosis Consider referral to endocrinologist and diabetes education centre See Diabetes Australia website for guidelines: 48 *UKPDS. Lancet 1998;352:837-53

49 Drug therapy recommendations for non-insulin hypoglycaemic drug therapy for patients with stages 3b 5 CKD CLASS CKD Complications Biguanide (Metformin) Second generation sulphonylurea Reduce dose Contraindicated GFR <60ml/min (PI) <30ml/min (RACGP) Contraindicated GFR<30ml/min Lactic acidosis Hypoglycaemia - glucosidase inhibitors SCr > 2 mg/dl: Avoid Hepatic toxicity TZDs Metiglinides GLP1 analogue Gliptins (DPP4 inhibitors) No dose adjustment No dose adjustment Contraindicated GFR<30ml/min Dose adjustment / use is variable depending on agent Volume retention, CHF?nil 49

50 Drug class target sites Liver Hepatic glucose overproduction Pancreas -cell dysfunction Biguanide TZDs Sulphonylureas Meglitinides GLP-1 analogs DPP 4 inhibitors Muscle and fat Insulin resistance Glucose level Kidney Renal glucose transport Biguanides TZDs SGLT2 Inhibitors -Glucosidase inhibitors 50 Gut Glucose absorption

51 Case study Peter Q4: What can be implemented to reduce Peter s blood pressure? a) Lifestyle modification? b) Medications? ACE-inhibitor, ARB or other drugs? Other? c) Do more tests? d) Refer on to an endocrinologist, nephrologist? 51

52 Hypertension in diabetes Lifestyle approaches are the first consideration in all people with diabetes and high blood pressure - the key elements are: SNAP - smoking, nutrition, alcohol, physical activity Stop smoking A low salt diet A reduction in his alcohol intake An exercise program A low calorie diet to reduce his BMI 52 For more details General Practice Management of Type 2 diabetes 2014/15

53 53 Lifestyle effects on BP Modification Weight reduction Dietary sodium restriction DASH diet Physical activity Moderate alcohol consumption only Recommendation BMI kg/m 2 Reduce dietary sodium intake to no more than 2.4g sodium (or 6g salt) Fruit, vegies, low saturated and total fat Aerobic activity for 30-60mins/day, 3-5 days/week No more than 2 drinks per day (men) or 1 drink per day (women) 4.4mmHg (for 5.1kg weight lost) 4-7mmHg (for reduction by 6g in daily salt intake) mmHg (5.5 for normotensives 11.4 for hypertensives) 5mmHg 3mmHg (for 67% reduction from baseline of 3-6 drinks per day) Tiberio MFrisoli et al Beyond salt; lifestyle modifications and blood pressure: European Heart Journal (2011) 32, doi: /eurheartj/ehr379

54 Hypertension in Diabetes 54 Medications may be needed to lower blood pressure to target levels The preferred anti-hypertensive agents in diabetes are an ACEinhibitor or ARB These agents may also slow progression of CKD Any other anti-hypertensive agent that lowers blood pressure will improve the patient s disease progression

55 Case study - Peter Peter has stage 3b CKD with macroalbuminuria and diabetes, so at high risk of a CVD event automatically and his blood pressure should be maintained consistently below 130/80mmHg Flag with his GP to consider: Starting a clinical action plan Lifestyle modification Pharmacotherapy to treat his hypertension Monitor 6-12 weekly until sufficient improvement People with... Maintain BP consistently BELOW (mmhg) Albuminuria <130/80 Diabetes <130/80 Chronic Kidney Disease <140/90 55

56 Orange Clinical Action Plan egfr ml/min/1.73m 2 with microalbuminuria OR egfr ml/min/1.73m 2 with normoalbuminuria Goals of management Investigations to determine underlying cause Reduce progression of kidney disease Assessment of Absolute Cardiovascular Risk Avoidance of nephrotoxic medications or volume depletion Early detection and management of complications Adjustment of medication doses to levels appropriate for kidney function Appropriate referral to a nephrologist when indicated 56 Chronic Kidney Disease (CKD) Management in General Practice, 3 rd edition. Kidney Health Australia: Melbourne, 2015

57 Orange Clinical Action Plan Frequency of monitoring Clinical assessment Laboratory assessment 3 to 6 months Blood pressure Weight Urine ACR egfr Biochemical profile including urea, creatinine, electrolytes HbA1c (for people with diabetes) Fasting lipids Full blood count Calcium and phosphate Parathyroid hormone (6-12 monthly if egfr <45 ml/min/1.73m 2 ) 57 Chronic Kidney Disease (CKD) Management in General Practice, 3 rd edition. Kidney Health Australia: Melbourne, 2015

58 Orange Clinical Action Plan egfr ml/min/1.73m 2 with microalbuminuria OR egfr ml/min/1.73m 2 with normoalbuminuria It is also important to consider Absolute Cardiovascular Risk Assessment ( Lifestyle modification Blood pressure reduction Lipid lowering treatments Glycaemic control 58 Chronic Kidney Disease (CKD) Management in General Practice, 3 rd edition. Kidney Health Australia: Melbourne, 2015

59 Screening and assessments Screening - search* for patients at risk and invite patients for a health check Health Assessments (Items 701, 703, 705, 707, 715) Screen those at risk Assessments Health Checks 59 Diabetes Family history of kidney failure Established CVD High blood pressure Obese (BMI >30kg/m 2 Smoker Aboriginal or Torres Strait Islander origin For more information visit A type 2 diabetes risk evaluation for people aged years (inclusive) with a high risk of developing type 2 diabetes as determined by the Australian Type 2 Diabetes Risk Assessment Tool once every 3 years to eligible patients A health assessment for people aged years (inclusive) who are at risk of developing chronic disease once only to an eligible patient *Use data management tools such as PEN CAT to help find patients at risk

60 Annual diabetes cycle of care Item 2517 Twice every 12 months At least once every 12 months Every 12 months Once every 2 years Weight Height Total Cholesterol Triglycerides Self Care education Diet Comprehensive eye examination BMI HDL-C Physical activity BP HbA1c Smoking evaluation Feet examination Microalbuminuria Medication Review egfr For more information visit 60 Diabetes Management in General Practice 14/15

61 Chronic disease management Medicare Australia has provided remuneration for chronic disease management by the following item numbers: GP Management Plan Other Items Items 721, 729 & 732 Items 723, 10997, For patient and GP management of chronic disease Incorporates patients goals, needs, achievements and references to resources Item 715 for Aboriginal and Torres Strait Islander Health Assessments Involves collaboration with other health professionals in patient care Electronic templates for specific conditions are available CKD template available at 61

62 Monitoring and support Item / For provision of monitoring and support to people with a chronic disease by a practice nurse or registered Aboriginal Health Worker, on behalf of a GP. Available for people who have a GPMP / TCA at a maximum of 5 services can be claimed per patient per calendar year. With 15 services available to Aboriginal or Torres Strait Islanders with a Health Assessment. The item may be used to provide: Checks on clinical progress - egfrs, ACR, BP Monitoring medication compliance - BP medication(s) Self management advice - personal goals Collection of information to support GP reviews of care plans For more information visit 62

63 Resources CKD patient fact sheets Available along with more kidney health fact sheets at 63

64 Case study Peter Q5: Who could you involve in Peter s management through a Team Care Arrangement? 64

65 Multidisciplinary Care Team May include, but is not limited to: Exercise Physiologist Dietitian Family Members / carers Community Health -weight and diet programs specific to local community Nephrologist Optometrist/ Ophthalmologist Endocrinologist Diabetes Specialist Renal Nurse Nurse Practitioner Pharmacist Podiatrist Social Worker Vascular/ Transplant Surgeon Cardiologist *N.B not all listed here are eligible for TCA inclusion. 65

66 Peter's management Q6: What will you review at Peter s next visit and when? The recommended period for a GPMP review is every 3-6 months. 66

67 Management reviews History Examination Investigation Review SNAP Patient s record of home testing Foot symptoms Weight Waist circ. Height HbA1c Intercurrent illnesses Goals BP 67 Diabetes Management in General Practice 14/15

68 Nurse role in CKD Reduce the impact of CKD Screen for risks Manage disease Monitor patient progress Using Kidney Health Check Diabetes Hypertension Cardiovascular using Absolute CVD Risk Calculator* Other CKD risk factors Using health checks & item numbers Using care plans and item numbers Promote self management Diabetes Hypertension CKD Symptoms Using item numbers Adherence to treatment Nephrotoxic medications *Refer to slide 36 68

69 Summary Optimal management of DKD Everyone with diabetes should have a kidney health check every year Targets of therapy and management change in those with DKD e.g. blood pressure, glycaemia etc. Major role for practice nurse in coordinating a multidisciplinary approach Kidney disease is an integral part of chronic disease management Overlap with diabetes management and CVD risk reduction Encourage self management 69 Potential to halve the number of patients presenting with kidney failure

70 Resources CKD management in General Practice 2015 guidelines handbook Available at health-professionals 70

71 Resources CKD-GO! Phone App Rated a must have App by Medical Observer Available on itunes and Google Play app stores All the best bits of the CKD Management in General Practice handbook now in a handy app! 71

72 Resources My Kidneys, My Health Handbook & App Free resource for patients newly diagnosed with early stage CKD App available on itunes and Google Play app stores 72 Hardcopy books available to order visit

73 Factsheet Resources Healthshare fact sheets Chronic Kidney Disease fact sheets for patients. Available for Medical Director and Best Practice software Urinary tract infections How to look after your kidneys Kidney Health Check up GP only Chronic Kidney Disease All about Chronic Kidney Disease Looking after yourself with CKD Kidney stones Kidney transplant Peritoneal dialysis Consent and kidney tests Kidney health tests Kidney cysts Access for dialysis Kidney cancer Treating kidney disease Homes haemodialysis Haemodialysis Life with a single kidney All about GFR 73

74 Resources Kidney Health Information Service Free call information service for people living with / affected by kidney disease 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 Information on advocacy opportunities and government relations issues Information on community and corporate events held by Kidney Health Australia 74 To join the kidney community, community@kidney.org.au

75 Thankyou for participating in this workshop Please complete your evaluation form before leaving. 75