Chronic kidney disease management primary care

Transcription

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 Classify stage according to egfr and structural renal disease Management Low risk Moderate risk High risk egfr 60 ml/ min/ 1.73m2 with microalbuminuria OR egfr ml/ min/ 1.73m2 with normoalbuminuria egfr ml/ min/1.73m2 with microalbuminuria OR egfr ml/ min/1.73m2 with normoalbuminuria Macroalbuminuria irrespective of egfr OR egfr <30 ml/ min /1.73m2 irrespective of albuminuria Goals of management Goals of management Goals of management Monitoring Monitoring REFERRAL Nephrologist Absolute Cardiovascular risk assessment tool Cardiovascular risk - high Monitoring Cardiovascular risk - high Interventions Blood pressure reduction Lipid lowering and glycaemic control Anaemia management Common drugs to avoid Preemptive Transplantation BP lowering agents Renal management towards the end of life REFERRAL Nephrologists Advanced Care Planning Page 1 of 13

2 1 Aboriginal and Torres Strait Islanders Aboriginal and Torres Strait Islander peoples [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 peoples: 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). If egfr < 60mL/min/1.73m2 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, Information resources for patients and carers Fact sheets from Kidney Health Australia 3 Care map information What is Chronic Kidney Disease (CKD)? [1] Page 2 of 13

3 Chronic kidney disease (CKD) is diagnosed as: an estimated or measured glomerular filtration rate (GFR) < 60 ml/min/1.73m2that 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, Classify stage according to egfr and structural renal disease Staging of CKD [1] Combine Kidney Function Stage (stage 1-5) with description of kidney damage (albuminuria) and clinical diagnosis to specify CKD fully (e.g., Stage 2 CKD with microalbuminuria, secondary to diabetic kidney disease). For people with CKD, the combination of low GFR and albuminuria places them at greater risk of CKD and CVD progression at all ages than those with just one of low GFR or albuminuria. See the Kidney Health Australia colour coded staging diagram for more information. Reference 12 Macroalbuminuria irrespective of egfr OR egfr <30 ml/min /1.73m2 irrespective of albuminuria Macroalbuminuria Urine ACR: Male > 25 mg/mmol; Female > 35 mg/mmol 24h urine albumin: > 300 mg/day Presents as frothy urine 13 Goals of management Goals of management [1] appropriate referral to a Nephrologist prepare for dialysis or preemptive transplant if egfr <30 ml/min/1.73m 2 discuss advanced care directive reduce progression of kidney disease Page 3 of 13

4 reduce CVD risk early detection and management of complications avoidance of nephrotoxic medications adjustment of medication doses to levels appropriate for kidney function multidisciplinary team involvement 14 Goals of management Goals of management establish diagnosis of kidney disease and exclude treatable kidney disease assessment and management of cardiovascular risk reduce rate of CKD progression consider earlier referral to nephrologist for younger people or people with significant decrease in renal function over 6 weeks 15 Goals of management Goals of management investigations to exclude treatable disease reduce progression of kidney disease reduce CVD risk early detection and management of complications avoidance of nephrotoxic medications or volume depletion adjustment of medication doses to levels appropriate for kidney function consider earlier referral to nephrologist for younger people or people with significant decrease in renal function over 6 weeks consider discussing advanced care directive 16 REFERRAL Nephrologist Referral to a Nephrologist Everyone in this category should be referred to a nephrologist (unless limited life expectancy for other reasons) The KHA-CARI guidelines recommend that individuals should be referred to a Nephrologist at least 12 months prior to the anticipated commencement of dialysis and/or kidney transplantation (i.e. referral when egfr <30 ml/min/1.73m 2 Tests to accompany referral: U&E / LFT Fasting glucose/lipids Page 4 of 13

5 Ca Po 4 ESR CRP Uric acid Full blood count PTH vit D Iron studies Renal ultrasound 24 hour urine protein and sodium excretion (if macroalbuminuria) Peninsula Health Frankston Hospital CKD clinic Ph: (03) Fax: (03) The Department of Nephrology provides inpatient care, acute dialysis and consultation for all patients admitted to Frankston Hospital with kidney problems. In addition, the department provides a range of outpatient clinics for chronic kidney disease, haemodialysis, peritoneal dialysis and transplant patients. Private nephrologists Nephrologist listings from National Health Service Directory Peninsula Renal Services 17 Hastings Rd, Frankston Phone: Fax: (03) Consultants: Dr Robert Flanc Dr Vinod Venkataraman Peninsula Specialists Clinc 118 Williams St, Frankston Mob Ph , Fax Dr Kim Wong Peninsula Private Hospital Consulating Suites 525 McClelland Dve Ph Fax Dr Alinda Chiu Details of relevant service providers are listed as a service for clinicians. Listing in this pathway is not an endorsement of the provider. If any relevant providers have been missed or if information is incorrect, please use the feedback button on the bottom right of the page to alert us. Page 5 of 13

6 17 Monitoring Monitoring 6-12 monthly clinical review clinical assessment blood pressure weight laboratory assessment urine ACR biochemical profile including urea, creatinine and electrolytes egfr HbA1c (for people with diabetes) fasting lipids 18 Monitoring Monitoring 3-6 monthly clinical review clinical assessment blood pressure weight laboratory assessment urine ACR biochemical profile including urea, creatinine and electrolytes egfr 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 ) 19 Absolute Cardiovascular risk assessment tool Absolute cardiovascular risk assessment People with CKD have a 20 times greater risk of dying from cardiovascular events than requiring dialysis or transplantation The presence of CKD is one of the most potent known risk factors for CVD. Perform absolute cardiovascular risk assessment using the Australian CVD tool for all adults aged years (35 years and above for Aboriginal and Torres Strait Islander peoples) without existing CVD and without a clinically determined risk factor Provide lifestyle and pharmacological management strategies (if indicated) based on the patient s risk level and clinical judgement Page 6 of 13

7 Australian absolute cardiovascular diesase risk calculator Australian cardiovascular risk charts Medical Director Cardiovascular Risk Calculator, under Tools>Tool Box Best Practice Cardiovascular risk under Clinical 20 Cardiovascular risk - high Cardiovascular risk People with CKD have a 20 times greater risk of dying from cardiovascular events than requiring dialysis or transplantation People with moderate or severe CKD (defined as persistently having a urine ACR >25 mg/mmol (males) or >35 mg/mmol (females) or egfr <45mL/min/1.73m 2 are considered to be at the highest risk of a cardiovascular event and do not need to be assessed by the cardiovascular risk tool. For these groups, identifying all cardiovascular risk factors present will enable intensive management by lifestyle interventions (for all patients) and pharmacological interventions (where indicated). See also lifestyle modification, blood pressure reduction, lipid lowering treatments, and glycaemic control 21 Monitoring Monitoring 1-3 monthly clinical review clinical assessment blood pressure weight oedema laboratory assessment urine ACR biochemical profile including urea, creatinine and electrolytes egfr HbA1c (for people with diabetes) fasting lipids full blood count (if anaemic see Page 30) calcium and phosphate parathyroid hormone (6-12 monthly if egfr < 45 ml/min/1.73m2 22 Cardiovascular risk - high Cardiovascular risk Page 7 of 13

8 People with CKD have a 20 times greater risk of dying from cardiovascular events than requiring dialysis or transplantation People with moderate or severe CKD (defined as persistently having a urine ACR >25 mg/mmol (males) or >35 mg/mmol (females) or egfr <45mL/min/1.73m 2 are considered to be at the highest risk of a cardiovascular event and do not need to be assessed by the cardiovascular risk tool. For these groups, identifying all cardiovascular risk factors present will enable intensive management by lifestyle interventions (for all patients) and pharmacological interventions (where indicated). 24 Preemptive Transplantation Preemptive Transplantation Preemptive transplantation means receiving a kidney transplant from a live donor prior to initiation of dialysis. Preemptive transplantation is associated with: reduced risk of death longevity of functioning of the transplanted kidney psychosocial benefits economic benefits A preemptive transplant can only be performed when the individual s kidney function has deteriorated to a level that justifies the risks and complications of transplantation (egfr usually 8-15 ml/min/1.73m 2 ), but before dialysis is needed. 25 Common drugs to avoid It is important to review renally excreted medications, as well as avoid nephrotoxic medications in people with CKD. Consider a Home Medicine Review. Commonly prescribed drugs that may need to be reduced in dose or ceased in CKD Antivirals Benzodiazepines Colchicine Dabigatran Digoxin Exenatide Fenofibrate Gabapentin Insulin Lithium Metformin* Opioid analgesics Saxagliptin Sitagliptin Sotalol Spironolactone Page 8 of 13

9 Sulphonylureas (all) Vildagliptin *use with caution if GFR ml/min/1.73m 2 ; not recommended if GFR < 30 ml/min/1.73m 2 Commonly prescribed drugs that can adversely affect kidney function in CKD NSAIDs and COX-2 inhibitors Beware the triple whammy of NSAID/COX-2 inhibitor, ACE inhibitor and diuretic (low dose aspirin is okay) Radiographic contrast agents Aminoglycosides Lithium Calcineurin inhibitors Over the counter medications/supplements E.g Vitamin C, precribed herbs should be specifically asked about Dosage reduction or cessation of renally excreted medications is generally required once the GFR falls below 60 ml/min/1.73m 2 26 Lipid lowering and glycaemic control Lipid-lowering treatments Lipid-lowering treatment should be considered where appropriate for CVD risk reduction. See the PBS guidelines for criteria to determine patient eligibility for subsidisation. Glycaemic control For people with diabetes, blood glucose control significantly reduces the risk of developing CKD, and in those with CKD reduces the rate of progression. 27 Blood pressure reduction BP target for reduction <140/90 for CKD with normoalbuminuria < 130/80 for CKD with albuminuria CKD can cause and aggravate hypertension, and hypertension can contribute to the progression of CKD. Reducing blood pressure to below threshold levels is one of the most important goals in management of CKD ACE inhibitor or ARB is recommended as first line therapy. Angiotensin converting enzyme inhibitor (ACEI) and angiotensin II receptor blocker (ARB) therapy is associated with a reduction in proteinuria and slowing of the rate of progression of kidney failure. Combined therapy of ACE inhibitor and ARB is not recommended. Maximal tolerated doses of ACE inhibitor or ARB is recommended. Page 9 of 13

10 Hypertension may be difficult to control and multiple (3-4) medications are frequently required ACE inhibitors and ARBs can cause a reversible reduction in GFR when treatment is 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 28 Anaemia management Anaemia of CKD is related to both: reduced erythropoietin production by the kidney resistance to the action of erythropoietin Anaemia related to CKD usually occurs at GFRs of <60 ml/min/1.73m 2. The prevalence of anaemia increases markedly with decreasing GFR. Management Other forms of anaemia should be considered and excluded. B12 and folate levels should be checked and corrected if deficient. Iron deficiency is a common cause of anaemia in people with CKD. If iron deficiency is identified any other cause should be excluded (e.g., blood loss). In people with CKD treated with erythropoiesis stimulating agents (ESA or EPO) iron supplementation is typically required. This can be given either as oral iron or not infrequently as intravenous supplementation (more information on IV supplementation such as Ferinject is available from NPS). Intramuscular iron is not recommended. 29 Renal management towards the end of life When egfr<30ml/min/1.73m 2 it may be necessary to consider end of life decisions including advanced care directives to outline wishes for future health and personal care, including non-dialysis treatment (no dialysis or transplantation), and palliative care arrangements[1]. Other indicators [2]: patients choosing not to have dialysis, discontinuing dialysis, or not opting for dialysis if their transplant has failed patients with difficult physical symptoms or psychological symptoms despite optimal tolerated renal replacement therapy symptomatic renal failure nausea and vomiting, anorexia, pruritus, reduced functional status, intractable fluid overload increasingly severe symptoms from co-morbid conditions requiring more complex management or which are difficult to treat : 1. Kidney Health Australia. Chronic Kidney Disease Management in General Practice. 2nd Edition The Gold Standard Framework (GSF). Prognostic Indicator Guidance. Walsall: GSF; BP lowering agents Page 10 of 13

11 ACEI and ARB ACEI or ARB can be safely prescribed in patients with any stage of kidney disease, bearing in mind the following points [1]: There is a significant risk of hyperkalaemia Stop the ACEI or ARB if potassium concentration is more than 6 mmol/l and does not respond to dose reduction, diuretic therapy and dietary potassium restriction. In patients with haemodynamically significant renal artery stenosis, ACEI and ARB can cause further impairment of glomerular perfusion in the affected kidney, and precipitate acute deterioration in kidney function. When commencing ACEI it is advisable to check renal function in 2 weeks then test monthly tests for 3 months, then test 3-6 monthly (KW). Monitor serum levels of creatinine and potassium closely. If the acute decrease in estimated glomerular filtration rate (egfr) is less than 25% below the baseline and stabilises within 2 months of starting therapy, the ACEI or ARB may be continued. If the decrease in egfr is greater than 25% below the baseline, stop the ACEI or ARB and refer the patient for investigation of possible bilateral renal artery stenosis. Take particular care in a patient with kidney disease treated with both an ACEI or ARB and a diuretic. Do not add a nonsteroidal anti-inflammatory drug (including selective cyclo-oxygenase-2 [COX-2] inhibitors) to this combination the 'triple whammy' as this can cause acute kidney failure. Most ACEI are renally excreted, and therefore lower doses are likely to be needed to control hypertension. Most ARB are predominantly excreted by the liver, so no dose adjustment is necessary. ACEI therapy may interfere with the actions of erythropoietin. Calcium channel blockers Calcium channel blockers are effective in BP control in patients with kidney disease, and are effective in slowing progression of kidney failure. Usually added to ACEI or ARB therapy, or used as an alternative to ACEI or ARB in patients who are intolerant of these drugs. Use lower doses of lercanidipine in patients with kidney disease, and titrate to effect. Dosage regimens of other calcium channel blockers are unaffected by kidney disease. Loop dieuretics At significantly reduced levels of kidney function (egfr less than 50 ml/min), loop diuretics are used, because thiazide diuretics are no longer effective. The dose should be adjusted according to the level of kidney function, commencing with frusemide 40 mg/day or bumetanide 1 mg/day, increasing gradually to a maximum frusemide dose of 500 mg/day or bumetanide 10 mg/day. High doses carry a risk of ototoxicity and should only be considered in consultation with a nephrologist. Beta blockers Some beta blockers (eg atenolol) are renally excreted, and dosage adjustment may be necessary in kidney disease. They can have deleterious effects on lipids and potassium. They are associated with erectile dysfunction in some patients, which may limit their use, as the incidence of impotence increases in kidney failure. Alpha blockers Alpha blockers can cause unacceptable orthostatic hypotension on initial dosage and when the dose is increased. In the longer term, increasingly higher doses may be needed to achieve the same effect, which limits their usefulness. However, occasionally they may be useful adjunctive therapy. Minoxidil The potent vasodilator minoxidil can be very effective in some patients with kidney disease and severe hypertension, but the associated sodium retention and tachycardia limit its use. Reference 1. Cardiovascular [revised 2012]. In: etg complete [Internet]. Melbourne: Therapeutic Guidelines Limited; 2014 Nov. Page 11 of 13

12 31 Advanced Care Planning Advanced Care Directives When egfr<30ml/min/1.73m 2 it may be necessary to consider end of life decisions including advanced care directives to outline wishes for future health and personal care, including nondialysis treatment (no dialysis or transplantation), and palliative care arrangements. Link to Advance Care Planning page 32 REFERRAL Nephrologists Referral criteria for nephrologist may include [1]: glomerular haematuria with macroalbuminuria egfr <30 ml/min/1.73m 2 persistent significant albuminuria (UACR 30 mg/mmol) consistent decline in egfr from a baseline of <60 ml/min/1.73m 2 (a decline >5 ml/min/1.73m 2 over a 6-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 antihypertensive agents. Peninsula Health CKD clinic Ph Fax: Consultant: Dr Kim Wong, Head of Nephrology Peninsula Health CKD Education Clinic Fax Consulatants: Dr Kim Wong, Head of Nephrology, Dr Alinda Chiu The Department of Nephrology provides acute care to patients admitted with kidney diseases. The range of services include acute dialysis for stable and unstable ICU/CCU patients, haemodialysis, peritoneal dialysis, hypertension management, general renal diagnosis and management, urgent and elective kidney biopsies services. The Department also provides a range of clinics for Haemodialysis, Peritoneal Dialysis, Pre-Dialysis education and end of life care services for patient with kidney diseases. Private nephrologists Nephrologist listings from National Health Service Directory Peninsula Specialists Clinc 118 Williams St, Frankston Mob Ph , Fax Dr Kim Wong Peninsula Renal Services 17 Hastings Rd, Frankston Phone: Fax: (03) Consultants: Page 12 of 13

13 Dr Robert Flanc Dr Vinod Venkataraman Peninsula Private Hospital Consulting Suites 525 McClelland Dve Ph Fax Dr Alinda Chiu Details of relevant service providers are listed as a service for clinicians. Listing in this pathway is not an endorsement of the provider. If any relevant providers have been missed or if information is incorrect, please use the feedback button on the bottom right of the page to alert us. Page 13 of 13

14 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

15 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