Chronic kidney disease screening and assessment

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1 Care map information Information resources for patients and carers Aboriginal and Torres Strait Islanders DEFINITION OF CKD egfr<60 ml/min/1.73 m2 and/or evidence of kidney damage for at least 3 months Who to screen for CKD? Clinical presentation RED FLAG - Acute nephritis - Acute kidney injury Screening Negative screen - return for yearly screen Urine tests - Albuminuria Measurements of egfr CKD investigation Go to CKD - primary care Page 1 of 6

2 1 Care map information What is Chronic Kidney Disease (CKD)? [1] Chronic kidney disease (CKD) is diagnosed as: an estimated or measured glomerular filtration rate (GFR) < 60 ml/min/1.73m 2 that is present for 3 months with or without evidence of kidney damage or evidence of kidney damage with or without decreased GFR that is present for 3 months as evidenced by the following, irrespective of the underlying cause: - albuminuria - haematuria after exclusion of urological causes - structural abnormalities (e.g., on kidney imaging tests) - pathological abnormalities (e.g., renal biopsy) [1] Chronic Kidney Disease (CKD) Management in General Practice (2nd edition). Kidney Health Australia, Melbourne, Information resources for patients and carers Patient fact sheets from Kidney Health Australia 3 Aboriginal and Torres Strait Islanders Aboriginal and Torres Strait Islander people [1] Age-standardised incidence of end stage kidney disease is significantly higher in Aboriginal and Torres Strait Islander peoples compared with non Aboriginal and Torres Strait Islander peoples. Recommendations for CKD detection in Aboriginal and Torres Strait Islander people: Indication for testing: 1. People years without any CKD risk factors: Assess for CKD risk factors(overweight and obesity, diabetes, elevated blood pressure, smoking, and family history of kidney disease As part of annual health assessment 2. People years with one of the following CKD risk factors: Family history of CKD or premature CVD Overweight/obesity Smoking Diabetes Elevated blood pressure AND all people 30 years: Recommended tests Urine ACR, egfr, blood pressure Frequency of testing: Every two years (or more frequently if CVD risk is elevated) Note. If urine ACR positive arrange 2 further tests over 3 months (preferably first morning void). Page 2 of 6

3 If egfr < 60mL/min/1.73m 2 repeat within 14 days. Source: National Guide to a preventive health assessment in Aboriginal and Torres Strait Islander peoples (NACCHO) (2012, in press). Benefits of identifying Aboriginal and Torres Strait Islander peoples: Clinician awareness of increased risk of CKD and cardiovascular disease and importance of screening other family members for CKD. Individuals able to access annual health check (Medicare item 715). Individuals eligible for Aboriginal and Torres Strait Islander peoples-specific pharmaceutical benefits. Individuals are eligible for Close the Gap PBS co-payments. The Aboriginal and Torres Strait Islander community becomes engaged with the health care system. For further detailed information refer to the NACCHO National Guide to a preventive health assessment in Aboriginal and Torres Strait Islander peoples ( [1] Chronic Kidney Disease (CKD) Management in General Practice (2nd edition). Kidney Health Australia, Melbourne, Who to screen for CKD? Who is at risk of CKD? [1] 1 in 3 adult Australians is at an increased risk of developing CKD. Adult Australians are at increased risk of developing CKD if they: are 60 years or older have diabetes have a family history of kidney disease have established cardiovascular disease have high blood pressure are obese (body mass index 30) are a smoker are of Aboriginal or Torres Strait Islander origin [1] Chronic Kidney Disease (CKD) Management in General Practice (2nd edition). Kidney Health Australia,Melbourne, Clinical presentation Presentation CKD is generally an asymptomatic condition. People with CKD may not notice symptoms until they reach stage 5 ( end-stage ), at which point the kidneys may be severely and irreversibly damaged Common symptoms of end-stage kidney disease are: nocturia lethargy malaise anorexia nausea vomiting pruritus restless legs ankle swelling Page 3 of 6

4 dyspnoea : 1. Johnson DW, Mathew T. Australian Doctor. 5 March How to Treat. Chronic Kidney Disease. 2. Chronic Kidney Disease (CKD) Management in General Practice (2nd edition). Kidney Health Australia, Melbourne, RED FLAG - Acute nephritis - Acute kidney injury Triggers for immediate referral Acute presentation with signs of acute nephritis (oliguria, haematuria, acute hypertension and oedema) [1] Acute kidney injury (AKI) with or without hyperkalaemia (creatinine increased by more than 20% or urine output < 0.5 ml/kg/hour for more than 12 hours).[2] 1. Chronic Kidney Disease (CKD) Management in General Practice (2nd edition). Kidney Health Australia,Melbourne, Lopes JA. Jorge S. The RIFLE and AKIN classifications for acute kidney injury: a critical and comprehensive review. Clin Kidney J (2013) 6: Screening If a patient has any one of : Diabetes Hypertension Smoking Obesity Established cardiovascular disease Family history of CKD Aboriginal or Torres Strait Islander Screening tests include: Urine ACR egfr Electrolytes Repeat yearly for people with the above risk factors if negative [1] Chronic Kidney Disease (CKD) Management in General Practice (2nd edition). Kidney Health Australia,Melbourne, Urine tests - Albuminuria Urine tests - Albuminuria [1] Consider CKD if ACR > 2.5 mg/mmol for males ACR > 3.5 mg/mmol for females Page 4 of 6

5 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. A positive ACR test should be repeated on a first void sample to confirm persistence of albuminuria. Albuminuria is said to be present if at least two out of three ACR results are positive (including the initial test). If the first positive ACR is a random spot (as it may be for opportunistic testing),then repeat tests should ideally be first morning void specimens. Dipstick for protein in the urine is now no longer recommended for this purpose as the sensitivity and specificity is not optimal. Urine PCR can be used for quantification and monitoring of proteinuria if required 24 hour urine collection is useful for quantification of protein and sodium excretion but is not necessary for screening. Approximate equivalents between urine ACR and other measures of protein excretion: Microalbuminuria Urine ACR: Male mg/mmol; Female mg/mmol 24h urine albumin: mg/day Macroalbuminuria Urine ACR: Male > 25 mg/mmol; Female > 35 mg/mmol 24h urine albumin: > 300 mg/day 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) [1] Chronic Kidney Disease (CKD) Management in General Practice (2nd edition). Kidney Health Australia,Melbourne, Measurements of egfr Blood tests glomerular filtration rate (GFR) [1] GFR is accepted as the best measure of kidney function. GFR can be estimated (egfr) from serum creatinine using prediction equations. egfr is recommended to be automatically reported (using the CKD-EPI equation) with every request for serum creatinine in individuals aged #18 years. If egfr is < 60 ml/min/1.73m 2, consider clinical situations where egfr results may be unreliable and/or misleading and retest within 14 days. If an initial egfr measurement is < 60 ml/min/1.73m 2, it is suggested that subsequent measurements of serum creatinine and calculation of egfr are carried out when the individual has fasted or specifically avoided a cooked meat meal in the four hours prior to blood sampling. An egfr < 60 ml/min/1.73m2 is common in older people, but is predictive significantly increased risks of adverse clinical outcomes, and should not be considered physiological or age-appropriate. A measured or estimated GFR < 60 ml/min/1.73m 2 is associated with increased risks of adverse renal, cardiovascular and other clinical outcomes, irrespective of age. Clinical situations where egfr results may be unreliable and/or misleading include: Page 5 of 6

6 acute changes in kidney function (e.g. acute kidney failure) 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 (e.g, fenofibrate, trimethoprim) [1] Chronic Kidney Disease (CKD) Management in General Practice (2nd edition). Kidney Health Australia, Melbourne, CKD investigation Tests to consider: MSU U&E / LFT Fasting glucose/lipids Ca PO 4 ESR CRP Uric acid Full blood count PTH vit D Iron studies Renal ultrasound Depending on clinical presentation (often requires specialist referral) immunoglobulin serum protein EP urine bence jones protein serum light chains HBV, HCV, HIV coagulation screen autoantibodies such as ANF, complement, antidna, ANCA Reference CKD pathway working group Page 6 of 6

7 Chronic Kidney Disease Medicine/Nephrology Provenance certificate Contents Overview Editorial methodology Contributors Disclaimers Overview This document describes the provenance of the Peninsula Pathways, Chronic Kidney Disease care map (pathway). This pathway was last updated in April The Peninsula Pathways Program aims to improve the continuity of patient care between primary, community and hospital care settings in the Frankston-Mornington Peninsula region. Work groups comprising of experienced health professionals (GPs, specialists, nurses, allied health professionals) were established to review and localise pathways. The objective of this pathway is to improve outcomes for patients with chronic kidney disease. To cite this pathway, use the following format: Map of Medicine (MoM). Chronic Kidney Disease. Frankston-Mornington Peninsula Medicare Local View. Melbourne: Map of Medicine; Editorial methodology This pathway is currently the first version localised to Frankston Mornington Peninsula. This pathway has been developed according to the Map of Medicine editorial methodology, using the evidence and expert advice of the international heart failure pathway as a starting point. The content of this care map was further developed with reference to Kidney Health Australia guidelines and other current evidence-based guidelines and practice-based knowledge provided by local practitioners with front-line clinical experience (see contributors section of this document). Contributors The following were clinical contributors to the Chronic Kidney Disease pathway: Dr Kim Wong Nephrologist, Head of Nephrology, Peninsula Health Dr Damian Flanagan General Practitioner Dr Glenn Mathieson General Practitioner

Chronic Kidney Disease Medicine/Nephrology Editor Nick Jones Service Integration Manager, Frankston Mornington Peninsula Medicare Local The following were contributors through the GP review committee

8 Chronic Kidney Disease Medicine/Nephrology Editor Nick Jones Service Integration Manager, Frankston Mornington Peninsula Medicare Local The following were contributors through the GP review committee and wider consultation process: Dr Jo Newton GP Liaison, Peninsula Health Dr Martin Coffey General Practitioner Dr Peter Meggyesy General Practitioner Dr Emma Donovan General Practitioner Conflicts of interest: None declared Disclaimer It is not the function of the Pathways Program, Frankston-Mornington Peninsula Medicare Local to substitute for the role of the clinician, but to support the clinician in enabling access to know-how and knowledge. Users of the Map of Medicine are therefore urged to use their own professional judgement to ensure that the patient receives the best possible care. Whilst reasonable efforts have been made to ensure the accuracy of the information on this online clinical knowledge resource, we cannot guarantee its correctness and completeness. The information on the Map of Medicine is subject to change and we cannot guarantee that it is up-to-date

Chronic kidney disease management primary care

Chronic kidney disease management primary care Care map information Information resources for patients and carers Aboriginal and Torres Strait Islanders DEFINITION OF CKD egfr