Section 4 - Management of diagnosed conditions

1. What is chronic kidney disease (CKD)?

• Healthy kidneys remove excess minerals, fluids and other waste products as urine
• Kidneys ability to remove waste products declines in the presence of chronic conditions and cardiovascular diseases
• As kidney function declines, potassium, uric acid and phosphate accumulates in the blood leading to gout, bone disease or abnormal heart rhythms
• CKD and end stage kidney failure occurs when kidney function is not addressed with lifestyle modification or medicines
• Two rising waste products in particular are used to measure how well the kidneys are functioning; creatinine and urea

2. Diagnosis of CKD ^2,5

• Patients commonly present asymptomatic but may have tiredness, anaemia, swelling around eyes and ankles, shortness of breath, anorexia, nausea, vomiting, urinary frequency especially at night, hypertension, itching, restless legs and chest pain
• Diagnosis relies on determining kidney function by two pathology tests:
  • eGFR which indicates how well the kidneys are filtering. Based on serum creatinine level and patient age and sex
  • albumin creatinine ratio (ACR) which is a measure of proteins in the urine. Excessive amounts are a key marker of kidney damage
• Diagnosis is made if either of the following features are present ≥ 3 months:
  • an eGFR < 60 mL/min/1.73 m² (CKD stage 3a–5. See Table 1.) with or without evidence of kidney damage OR
  • evidence of kidney damage with or without decreased eGFR:
    • albuminuria i.e. persistent positive ACR result for 3 or more months
    • haematuria after exclusion of infective urological or menstrual causes
    • structural abnormalities e.g. on kidney imaging tests
    • pathological abnormalities e.g. renal biopsy

• Early detection and management of CKD can slow progression to end-stage renal failure
• All high risk groups should be offered an annual ACR and eGFR. See Pathology (adult)
• All newly diagnosed patients with CKD should be referred to a nephrologist
  1. ACR urine test ²
     • ACR measures protein in the urine; a key marker of kidney damage:
       • performed on a single urine sample (most accurate first morning void)
       • normal values are < 3.5 mg/mmol for women and < 2.5 mg/mmol for men
       • considered positive when above values are exceeded
       • albuminuria is present when 2 out of 3 ACR tests are positive
       • kidney damage is likely if albuminuria is persistent for 3 or more months
  2. eGFR blood test ²
     • eGFR is the best measure of kidney function
     • Normal eGFR is > 90 mL/min/1.73m². Further investigations are only done if the eGFR value drops below 60
     • An eGFR < 60 mL/min/1.73m² should be considered in the context of other clinical situations and be retested in 7 days. These include:
       • acute changes in renal function
       • dialysis patients
       • dietary intake. See 3.3 Diet and nutrition
       • extremes of body size
       • muscle diseases (may overestimate) or high muscle mass (may underestimate)
       • children < 18 years of age
       • severe liver disease
     • An eGFR < 60 mL/min/1.73m² in the elderly, although common, should be treated as significant and not considered physiological
  3. Staging, classification and progression of CKD ^2,5
     • While the stage of kidney function is determined by eGFR, the risk of CKD progressing is calculated by correlating eGFR against ACR. See Table 1.
     • The risk of progression determines CKD management

3. Management of CKD ^1,2,6,7,8

• The goal of managing CKD is to prolong quality of life by modifying lifestyle behaviours while identifying and addressing comorbidities including:
  • Dyslipidaemia
  • Hypertension (most effective way of slowing CKD progression)
  • Diabetes (most common cause of CKD)
  • Coronary heart disease
• Address these comorbidities in conjunction with the Australian cardiovascular disease risk calculator
• Management targets for CKD are outlined in Table 2.

1. Support patient self-management ²
   • In partnership with the patient and family assess the impact of CKD on:
     • activities of daily living
     • physical activity
     • employment
     • finances
     • family routines
     • social-emotional wellbeing
   • Discuss what CKD is and how and why it progresses to end stage CKD. See 3.6 End stage CKD (Stage 5)
   • Provide Resource 2.
   • Consider referral to physiotherapist or occupational therapist to assess home for falls risk and support requirements. See Resource 3.
   • Refer eligible aged care patients to My Aged Care. See Resource 4.
   • Encourage the patient to identify barriers to adequate lifestyle modification and
     medical adherence, and create goals to overcome those barriers. See Engaging our patients
2. Social-emotional support ²
   • Depression can affect 1 in 5 people with CKD, and 1 in 3 individuals on dialysis
   • Depression in people with CKD has detrimental affects on mortality, hospitalisation rates, medicine and treatment adherence, nutrition and overall quality of life
   • Cognitive impairment is common in people with CKD and prevalence increases with CKD severity and end stage CKD. Manage as per Dementia
   • See Social-emotional wellbeing
3. Diet and nutrition ^1,2,10,11
   • All people with CKD should be encouraged to eat a balanced diet according to national recommendations. See Diet and nutrition
   • Refer all patients with eGFR < 30mL/min/1.73m² to a dietitian for an individualised dietary plan
   • Patients with eGFR > 30mL/min/1.73m² should:
     • consume a normal protein diet. Avoid high or low protein intake
     • avoid salt and salt substitute intake to reduce blood pressure and albuminuria
     • drink fluids to satisfy thirst. Avoid soft drinks
   • Refer patients with a BMI > 25kg/m² to a dietitian or exercise physiologist for an individualised dietary and exercise plan
   • Do not restrict dietary phosphate in kidney function stage 1–3
   • Provide CKD dietary information. See Resource 5.
4. Vitamin D ^2,22
   • As GFR falls, activation of vitamin D is impaired
   • It is difficult to obtain sufficient vitamin D from diet alone
   • Those with early CKD should expose their face, hands and arms to the sun for:
     • 6–7 minutes before 10am and after 3pm in summer and 7–40 minutes at midday in winter (at UV index < 3) for most days of the week for fair-skinned people
     • 10–15 minutes on most days of the week for naturally dark skinned people
   • Managing vitamin D levels in end stage CKD can be difficult. Consult a nephrologist
5. Obstructive sleep apnoea (OSA) ²
   • Affects up to 50% of people with eGFR <15 mL/min/1.73m²
   • Is a significant cause of refractory hypertension
   • Manage by:
     • weight reduction. See Overweight and obesity (adult) and Lifestyle modifications
     • avoid central nervous system depressants e.g. opiates and alcohol
     • CPAP therapy
   • Assess a patient’s daytime sleepiness and OSA risk by using a validated tool. If they score highly refer to a sleep specialist. See Resource 6.
6. End stage CKD (Stage 5)
   • Provide patient and carer support for:
     • adjustment to diagnosis
     • grief and loss support
     • access to kidney support services
     • family meetings to ensure patient and family awareness
     • confirmation that patient, family and carer wishes are compatible with care required
     • spiritual and cultural needs
   • Discuss end of life decisions including:
     • dialysis options. See 3.7 Dialysis below
     • advance care directives (wills, guardianship etc.) to outline wishes for future health and personal care. See Advance Care Planning
     • no dialysis and palliative care arrangements. See Palliative care
   • While in chronic kidney failure it is appropriate to:
     • avoid high-protein foods to limit the progression of uraemia
     • continue erythropoietin stimulating agent (ESA) to prevent anaemia and improve fatigue
     • correct calcium, phosphate and magnesium imbalances
7. Dialysis ²
   • Refer all patients with an eGFR > 15–29 mL/minute (Stage 4) to a nephrologist to consider dialysis
   • Discuss with the patient:
     • dialysis is a choice that requires commitment
     • some comorbidities, especially cardiac disease, preclude dialysis
     • the burden of dialysis regimen and treatment of comorbidities. See Table 3.
     • health may deteriorate despite dialysis with few other treatment options i.e. transplantation or conservative care
     • dialysis is ceased when the quality of life without dialysis outweighs its benefits
     • what happens when dialysis is ceased, refused or ceases to be of benefit:
       • conservative kidney care. See Table 3.
       • deterioration depends on comorbidities and kidney function
       • mortality varies from weeks to years. Family and carers may expect a rapid death

4. Medicines for those with CKD

1. Calculating CKD medicine dosage ^2,16
   • Either eGFR or Creatinine Clearance (CrCl) can be used to estimate renal medicine clearance, however these values are not interchangeable or equivalent
   • eGFR is the preferred measure of kidney function with appropriate adjustment of body surface area (BSA) for patient's with:
     • eGFR/CrCl < 30mL/min
     • body weight < 50kg
     • BMI > 30kg/m²
   • Calculators to estimate CrCl and ideal body weight are also available online. See Resource 7.
2. Special considerations ^{2,8–10,12,14–17,19,20}
   • Medicines should be regularly reviewed by a nephrologist, MO/NP or pharmacist especially when CrCl is < 10 mL/min
   • Use of uric acid lowering agents e.g. allopurinol, are not routinely recommended in people with early CKD (stage 1–3) who have asymptomatic hyperuricaemia

• Refer to a clinically accepted renal medicines handbook, specialist or pharmacist where medicine dosage adjustment may be required for antibiotics or antivirals
• Educate patients to avoid over the counter NSAIDs without consultation
• Reduce maximum metformin dose when:
  • CrCl 60–90 mL/minute, 2 g PO daily
  • CrCl 30–60 mL/minute, 1 g PO daily
  • CrCl 15–30 mL/minute, 500 mg PO daily
• Radio-contrast can cause further renal damage
• For those with end stage CKD, medicines may need to be ceased or doses reduced to prevent accumulation of metabolites
• For the use of opioids see Persistent pain
• Flowchart 1. illustrates medicine management of hypertension in patients with CKD

3. Cholesterol-lowering treatment ^6,7,14–16
   • Use statin or statin/ezetimibe combination in those:
     • ≥ 50 years with any stage of CKD
     • < 50 years with any stage of CKD in the presence of one or more of:
       • coronary disease
       • previous ischaemic stroke
       • diabetes or
       • estimated 5 year cardiovascular disease risk is high > 10%. See the Australian cardiovascular disease risk calculator
   • No target lipid levels or follow-up is required

Flowchart 1. Management of hypertension in people with CKD ²

5. Cycle of care

6. References

• All Chronic Conditions Manual references are available via the downloadable References PDF

7. Resources

1. For further clinical prioritisation criteria for nephrology referral
2. Patient and professional resources from Kidney Health Australia
3. Individual falls risk screening
4. The Australian Government’s My Aged Care portal for all national aged care support services
5. CKD dietary information handout and CKD and dialysis dietary information handout and Aboriginal and Torres Strait Islander specific handout
6. The Epworth Sleepiness Scale and STOP-Bang questionnaire
7. The Australian Medicines Handbook online calculators: The CrCl calculator, the ideal weight calculator, the Body surface area calculator and the Queensland Health Heart Failure Medicine Titration Plan