National Guide

Chapter 18 | Chronic kidney disease







National Guide to preventive healthcare for Aboriginal and <br/>Torres Strait Islander people
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    19. Chapter 18 | Chronic kidney disease

Chronic kidney disease

Dr Mary Belfrage, Prof William Majoni 

Key messages

  • The detection and management of risk factors is critical for the prevention of chronic kidney disease (CKD).1,2
  • Social and political determinants of health, such as poverty, living conditions and racism, contribute to CKD in Aboriginal and Torres Strait Islander populations.1,3
  • Major modifiable risk factors in Aboriginal and Torres Strait Islander people are the same as those in non-Indigenous Australian people, including low birth weight, diabetes, hypertension, cardiovascular disease (CVD), obesity and smoking.2
  • There are strong associations and compounding interactions between CKD, CVD and diabetes.
  • Primary healthcare teams play a critical role in the prevention, early detection and management of risk factors for CKD and in the early detection and management of CKD.2
  • Early detection of CKD and instituting effective evidence-based treatments prevent or slow progression and complications.2
  • Shared decision making between clinicians and patients and supported self-management are central to effective care of people with CKD.1
Type of preventive activity - Screening
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
People aged over 18 years without any CKD risk factors Screen for red flags and additional considerations of CKD (see Box 2) At least annually Strong CARI guidelines1 Suports primary prevention of CKD
People aged 18 years or over Complete kidney health check (blood pressure, eGFR, ACR)

If ACR is raised, repeat once or twice over three months (first void specimens if possible)		 At least annually Strong Aboriginal and Torres Strait Islander-specific guidelines1 Suports primary prevention and early detection of CKD
Type of preventive activity - Behavioural
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
Adults with any risk factors for CKD Offer individualised, structured education about healthy living and health risk behaviours:
  • Optimise mental health
  • Regular physical activity
  • Healthy eating
  • Healthy weight/weight loss
  • Smoking cessation
 Opportunistically Strong Aboriginal and Torres Strait Islander-specific and national guidelines1,2 Suports primary prevention of CKD
Adults with CKD Stages G1–G3 (see Box 1) Offer individualised, structured education about healthy living and health risk behaviours:
  • Optimise mental health
  • Regular physical activity
  • Healthy eating
  • Healthy weight/weight loss
  • Smoking cessation
  • Safe alcohol guidelines
 As part of clinical care plan Strong Aboriginal and Torres Strait Islander-specific and national guidelines1,2 Can significantly slow the progression of CKD
Adults with CKD Stages G1–G3 (see Box 1) Refer to secondary care early as per guidelines

Note lower thresholds for referral in Aboriginal and Torres Strait Islander population (see Figure 1)		 As clinically indicated Strong Aboriginal and Torres Strait Islander-specific and national guidelines1,2 Early referral to nephrology services is associated with slower progression of CKD and better outcomes.
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Type of preventive activity - Medications
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
All people with CKD Regularly review medications to identify and avoid those with potential nephrotoxicity

Advise patients taking an angiotensin-converting enzyme (ACE) inhibitor or angiotensin II receptor blocker (ARB) plus diuretic to avoid non-steroidal anti-inflammatory drugs (NSAIDs; other than low-dose aspirin if indicated)

Advise patients which medications to avoid when acutely unwell or fasting (SAD MANS [Sulfonylureas; ACE inhibitors; Diuretics;

Metformin; ARBs; NSAIDs; Sodium–glucose cotransporter 2 inhibitors {SGLT2}]; see Box 3)		 Opportunistically and at every medication change Good practice point National guidelines2,4 Need to avoid any nephrotoxicity that further compromises renal function
All people with CKD Follow clinical action plans and goals of treatment as per guidelines at all stages of CKD

Work in partnership with patients to support self-management (eg diet, physical activity and self-monitoring of blood pressure [BP]; note, target home systolic BP of 115 – 125 mmHg, if tolerated)		 Ongoing clinical management Strong Aboriginal and Torres Strait Islander-specific and national guidelines1,2 To preserve kidney function and optimise quality of life and wellbeing.
Supported self-mamnagement supports better clinical outcomes.
Adults with albuminuria Advise treatment with an ACE inhibitor or ARB, regardless of eGFR or BP level, but avoid symptomatic hypotension

An ACE inhibitor and ARB should not normally be prescribed together
(Note, target home systolic BP 115–125 mmHg if tolerated)		 At diagnosis Strong National guidelines2
International guideline update5		 Specific clinical target as per guidelines
Adults with albuminuria Advise minimising salt intake to <6 g per day At diagnosis Strong National guidelines2  
Adults with albuminuria Advise treatment with SGLT2 inhibitor As clinically indicated Strong International guideline update5 New recommendation 2022
See the Kidney Disease: Improving Global Outcomes (KDIGO) 2022 clinical practice guideline update of diabetes management in CKD5
Adults with CKD and diabetes Aim for optimal diabetes control, healthy weight, medications and clinical targets as per guidelines Ongoing clinical management Strong National guidelines2 As per guidelines
Adults with CKD and diabetes Advise treatment with SGLT2 inhibitor regardless of HbA1c
Consider non-steroidal mineralocorticoid receptor antagonists in addition to an ACE inhibitor/ARB and SGLT2 inhibitor if ACR is 200 mg/g (ie ≥23mg/mmol) despite maximum tolerated dose of ACE inhibitor/ARB

Consider glucagon-like peptide-1 receptor agonist if not meeting glycaemic targets on first-line therapy		 As clinically indicated Strong International guideline update5 New recommendation 2022
See the Kidney Disease: Improving Global Outcomes (KDIGO) 2022 clinical practice guideline update of diabetes management in CKD5
Type of preventive activity - Environmental 
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
Communities with a high prevalence of scabies and pyoderma Support the implementation of population-based strategies for the reduction of scabies and pyoderma among children (refer to Chapter 6: Child health, Childhood kidney disease and Chapter 12: Acute rheumatic fever and rheumatic heart disease)

Support strategies to reduce socioeconomic disadvantage		 Opportunistically Strong Narrative review and regional initiative6,7 To reduce the risk of post-streptococcal glomerulonephritis
 



 

Box 1. Classification of chronic kidney disease2

The colours indicate recommended clinical action plans in Chronic kidney disease (CKD) management in primary care.2 Green indicates no CKD yellow, orange and red indicate increasing severity of CKD.

Patients with CKD are classified using Stages G1–G5 based on the glomerular filtration rate (GFR), and Stages A1–A3 based on the urine albumin:creatinine ratio (ACR). Note that Stage G2 CKD requires evidence of kidney damage in addition to a reduced glomerular filtration rate (GFR), whereas Stages G3A–G5 are defined on the basis of GFR alone.

 

Box 2. Susceptibility to chronic kidney disease1
Red flags (risk factors) Additional considerations for Aboriginal and Torres Strait Islander people
  • Family history of CKD
  • Diabetes
  • Hypertension
  • Obesity (BMI >30 kg/m2)
  • Established cardiovascular disease
  • History of acute kidney injury
  • Smoking
  • History of low birthweight
  • History of recurrent childhood infections
  • Remoteness
  • Low socioeconomic status
  • Housing insecurity and overcrowding
  • Education levels
  • Other impacts of colonisation
BMI, body mass index; CKD, chronic kidney disease.

Figure 1. Criteria for referral to secondary care.
Reproduced with permission from Recommendations for culturally safe and clinical kidney care for First Nations Australians.1

Box 3. Medications to avoid in chronic kidney disease when dehydrated or fasting: SAD MANS
  • S: Sulfonylureas such as glyburide, gliclazide
  • A: ACE inhibitors such as ramipril, perindopril
  • D: Diuretics such as hydrochlorothiazide, indapamide
  • M: Metformin
  • A: ARBs such as candesartan and irbesartan
  • N: NSAIDs such as ibuprofen and diclofenac
  • S: SGLT2 inhibitors such as dapagliflozin, empagliflozin
ACE, angiotensin-converting enzyme; ARBs, angiotensin II receptor blockers; NSAIDs, non-steroidal anti-inflammatory drugs; SGLT2, sodium–glucose cotransporter 2.
  • Maintain up-to-date medications on the primary care record and My Health Record and provide patients with an up-to-date medication list.
  • Use recalls to make sure all people with CKD have regular review.
  • Conduct a relevant clinical audit; for example:
    • ensure appropriate medications, including new medications
    • care pathways (as per guidelines)
    • recommendations for early referral.

Background

CKD in adults is defined as either glomerular filtration rate (GFR) <60 mL/min/1.73 m2 and/or kidney damage (albuminuria, haematuria not due to urological causes and confirmed structural and/or pathological abnormalities) persisting for at least three months.2 CKD is classified into five stages based on the combined indices of kidney function (measured [or estimated] GFR [eGFR]; G) and three stages based on albuminuria (A), regardless of the underlying diagnosis, as outlined in Box 1.2

Aboriginal and Torres Strait Islander people have a very high prevalence of CKD with onset often at a young age,3,8 and are approximately five-fold more likely than non-Indigenous Australians to develop kidney failure, with middle-aged women being at particularly high risk.3,9

The decline in GFR appears to be faster in Aboriginal and Torres Strait Islander individuals than in non-Indigenous Australian individuals, and increased albumin excretion is a powerful predictor of GFR decline.10 However, there is considerable variation in the prevalence of CKD among Aboriginal and Torres Strait Islander communities; rates are highest in remote areas and lowest in urban areas.3,8,11,12 Rates of CKD are also strongly correlated with socioeconomic disadvantage.3,9,13 The reasons for the high rates of CKD are multifactorial,14 but important modifiable risk factors in Aboriginal and Torres Strait Islander people are thought to be the same as those in non-Indigenous Australians: low birth weight, diabetes, hypertension, CVD, obesity and smoking.1,2,8,9,15 Recent evidence confirms high rates of co-existing CKD and diabetes and high rates among younger people.16

There are strong links between CKD, CVD and diabetes. 2 Reduced GFR and raised urinary albumin excretion are independent risk factors for mortality.17–19 The bulk of this mortality is due to CVD, and people with CKD are at higher risk of dying from CVD than they are of progressing to kidney failure.20,21 Even a mild reduction in GFR is associated with excess cardiovascular and stroke risk,22,23 whereas at any given level of kidney function albuminuria is associated with increased cardiovascular and stroke morbidity and mortality.24,25
New Australian guidelines for Aboriginal and Torres Strait Islander people, Recommendations for culturally safe and clinical kidney care for First Nations Australians, were published by CARI Guidelines in 2022.1 These guidelines were developed in consultation with Aboriginal and Torres Strait Islander  people, including clinicians, as well as locally based consumers/communities and services, and make specific recommendations about racism, how risk is characterised, the importance of culturally appropriate and safe services, the importance of self-management, shared decision making and patient-centred care, as well as clinical recommendations and a range of other cultural considerations in how healthcare is provided.1

The other key guideline informing recommendations in this guide is Chronic Kidney Disease (CKD) Management in Primary Care: Guidance and clinical tips to help detect, manage and refer patients in your practice with CKD, fourth edition published by Kidney Health Australia in 2020.2 These guidelines have detailed clinical action plans according to each grade of CKD, including medication advice and clinical targets.

Primary prevention

Addressing the social and environmental determinants of CKD is largely outside the scope of this guide, but primary care services play a critical role in identifying and optimising the management of risk factors for CKD, which constitutes primary prevention.1,2 Robust epidemiological evidence and plausible biological explanations for the association of low birth weight, overweight and obesity, diabetes, hypertension and smoking with CKD suggest that interventions to prevent diabetes,26,27 to promote exercise, healthy diet and normal weight, to limit or reduce salt intake and to discourage smoking have the potential to also reduce the incidence of CKD.28–31 Programs to promote maternal health during pregnancy and healthy birth weight, as well as to prevent streptococcal infection in childhood, may also reduce the future risk of CKD.32 In adults, postinfectious glomerulonephritis is associated with poor renal prognosis and progression of CKD, so preventing and effectively treating infections is critical.33

Screening and early detection

Australian guidelines for Aboriginal and Torres Strait Islander people support the efficacy and cost-effectiveness of screening for CKD risk factors and for CKD in Aboriginal and Torres Strait Islander peoples1 (see Box 2). These guidelines recommend age-appropriate health assessments to screen for CKD, at least annually to support the identification and assessment of red flags (risk factors) and additional considerations, as well as the early detection of CKD1 (Figure 2).

 

Figure 2. Chronic kidney disease (CKD) screening matrix for Aboriginal and Torres Strait Islander people. ACR, albumin:creatinine ratio. Reproduced with permission from Recommendations for culturally safe and clinical kidney care for First Nations Australians.1

GFR testing

In clinical practice, GFR is estimated (eGFR) from serum creatinine and other parameters, including sex and age, using the CKD Epidemiology Collaboration (CKD-EPI) formula.34 This formula has been shown to perform well in Aboriginal and Torres Strait Islander people, both with and without diabetes.35 However, eGFR formulas do not apply in acute kidney injury, and factors such as intercurrent illness, certain diets, underweight, overweight, muscle diseases, high muscle mass or severe liver disease can impact eGFR and should be considered when interpreting eGFR results.2 A confirmed reduction in GFR should be investigated with midstream urine (infection, pyuria, haematuria), paired urine testing for both albumin and protein and an ultrasound to inform diagnosis and next steps.

Proteinuria and albuminuria testing

Some albumin is excreted by healthy kidneys (ACR <2.5 and <3.5 mg/mmol in men and women, respectively), but elevated albumin (albuminuria) or total protein in the urine (proteinuria) is an important marker of kidney damage.2 The proportion of total urine protein that is albumin rises from <10% in normal urine to around 50% with abnormal proteinuria.36 Abnormal albumin excretion is classified as microalbuminuria (defined as ACR 2.5–25 and 3.5–35 mg/mmol in men and women, respectively) or macroalbuminuria (defined as ACR >25 and >35 mg/mmol in men and women, respectively;2 see Box 1), with levels >300 mg/mmol designated as being in the nephrotic range and levels >300 mg/mmol associated with low serum albumin, oedema and raised cholesterol designated as nephrotic syndrome.

In diabetes, and under most other circumstances, measurement of urinary albumin is a more sensitive test for the first sign of CKD than testing for total protein; in the AusDiab baseline study, only 8% of adults with proteinuria tested negative for albuminuria (non-albumin proteinuria).36,37

Most Australian and international guidelines recommend screening for albuminuria rather than proteinuria for the detection of CKD,1,2 although in severe nephrotic syndrome, measuring total proteinuria is more robust. It is important to note that not all individuals with CKD exhibit abnormal albumin or protein excretion, and that a small proportion of patients with abnormal proteinuria, such as those with renal ischaemia from established vascular disease or smoking, tubulointerstitial disease and myeloma, may excrete abnormal amounts of non-albumin protein only. 37

Albumin excretion may be increased by urinary tract infection, acute febrile illness, high dietary protein, heart failure, recent heavy exercise, some drugs, and menstruation or vaginal discharge.2 The definition of abnormal albuminuria requires at least two elevated ACR measurements in a three-month period (ie an abnormal ACR result on screening needs to be repeated to confirm that the result is not a false positive).38,39 Confirmed abnormal albuminuria should be investigated with midstream urine (infection, pyuria, haematuria), paired testing of both albumin and protein and an ultrasound to inform diagnosis and next steps.

Laboratory measurement of the ACR should be done on morning first-void specimens, but can be provided on random spot urine specimens.1,2 Point-of-care ACR testing is available in some settings.

Secondary prevention

Active treatment of CKD, once detected, can slow progression to kidney failure and reduce cardiovascular endpoints.2 Active treatment includes managing health risk behaviours: patients should be helped to quit smoking,28 consume a healthy diet and healthy drinks, reduce excess weight40 and take regular exercise.31 Limiting dietary sodium intake to no more than 100 mmol (approximately 6 g = one teaspoon of salt) per day may reduce both blood pressure and urinary albumin excretion.40

Engaging patients in self-management is aided by graphical displays of serial results over 5–10 years, home monitoring of BP to maintain target systolic BP at 120–130 mmHg, having Aboriginal and Torres Strait Islander health workers/health practitioners in the care team to aid two-way communication and outreach clinics.

An ACE inhibitor or ARB is generally the first-line treatment for lowering BP and reducing protein excretion. These two classes of drug should not normally be prescribed together. Although the combination may be more effective than monotherapy in reducing both BP and proteinuria, coprescribing is associated with an increase in adverse effects and worse renal outcomes.2,5

Many long-term beneficial medications can worsen the risk of acute kidney injury while acutely unwell, and need to be temporarily withheld, but then restarted after recovery. Proton pump inhibitors are widely prescribed long term, but can cause subacute acute kidney injury from interstitial nephritis, as well as slowly progressive CKD, so their risk–benefit ratio should be considered carefully and either they should be used only as required or non-nephrotoxic histamine H2 receptor blockers substituted where appropriate.41

Statins lower death and major cardiovascular events in people with CKD not requiring dialysis.42,43 The effects of statins on stroke and the progression of CKD are uncertain.

SGLT2 inhibitors are a more recent and effective addition to the management of CKD in people both with and without diabetes. SGLT2 inhibitors prevent a decline in kidney function by reducing glomerular hypertension mediated through tubule–glomerular feedback, which is independent of their effect on glycaemic control.44 Current updated international guidelines recommend the use of SGLT2 inhibitors among all patients with type 2 diabetes and CKD (based on albuminuria or low eGFR without albuminuria) with an eGFR of at least 20 mL/min/1.73 m2.5

Long-acting glucagon-like peptide-1 receptor agonists have short-term beneficial effects on CKD and albuminuria (above and beyond their benefits on weight loss and diabetic control), monitoring carefully for gastrointestinal tolerance, with long-term trial outcomes expected shortly.45 Non-steroidal mineralocorticoid receptor antagonists also retard progressive CKD and reduce albuminuria, but need careful monitoring to avoid raised serum K+ in more advanced CKD Stage 4–5, with temporary omission while dehydrated or fasting.48 (See Box 3 for medications to avoid when dehydrated or fasting.)

Referral to secondary care

The recommendations in this guide are concerned with preventing kidney disease, detecting and slowing the progression of established CKD and reducing the associated risks of cardiovascular disease and stroke. Although they are all amenable to delivery in the primary care setting, patients with more advanced disease and/or significant comorbidities, or those at risk in other ways, are likely to benefit from referral to a secondary care nephrology service.1,2 Australian guidelines recommend referral of Aboriginal and Torres Strait Islander patients with any of the following:

  • eGFR <45 mL/min/1.73 m2
  • persistent significant albuminuria (ACR ≥30 mg/mmol)
  • a sustained decrease in eGFR of >10 mL/min/1.73 m2 within 12 months
  • CKD and elevated BP that is difficult to treat or not at target despite at least three BP-lowering medications.1,2

Referral should be performed as early as possible because late referral is associated with poorer outcomes.1,2

 
 
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