In 2020, the Chronic Kidney Disease (CKD) Management in Primary Care (4th Edition) handbook was released by Kidney Health Australia, replacing the 2015 3rd Edition. The handbook provides guidance and clinical tips to help detect, manage and refer patients in your practice with CKD. Provided here is a summary of the key information.

CKD Essentials

Definition of CKD

 

Algorithm for initial detection of CKD

 

Treatment goals for people with CKD

Parameter	Treatment goal	For more info
Diet and nutrition	Consume a varied diet rich in vegetables, fruits, wholegrain cereals, lean meat, poultry, fish, eggs, nuts and seeds, legumes and beans, and low-fat dairy products. Limit salt to <6g /day (≤100mmol/day). Limit intake of foods containing saturated and trans fats. Limit intake of foods containing added sugars. Drink water to satisfy thirst. Avoid high calorie sweetened carbonated beverages at all costs. Dietary protein no lower than 0.75 g/kg body weight / day. Maintain Serum albumin ≥35 g/L.	See page 38 of the Handbook Australian dietary guidelines Accredited Practising Dietitian
Obesity	Ideal weight should be BMI ≤25. Waist circumference <94cm in men (<90cm in Asian men) or <80cm in women (including Asian women).
Physical activity	Be active on most, preferably all, days every week. Accumulate 150 to 300 minutes (2 ½ to 5 hours) of moderate intensity physical activity or 75 to 150 minutes (1 ¼ to 2 ½ hours) of vigorous intensity physical activity, or an equivalent combination of both moderate and vigorous activities, each week. Do muscle strengthening activities on at least 2 days each week. Refer to Physical Activity and Sedentary behaviour guideline for age specific recommendations.	Australia’s physical activity and sedentary behaviour guidelines Exercise physiologist
Smoking	Stop smoking using counselling and, if required nicotine replacement therapy or other medication.	Quitline 13 7848
Alcohol	Limit intake to ≤2 standard drinks per day to reduce risk of alcohol – related disease or injury over a lifetime. Do not drink >4 standard drinks on any single occasion.	NHMRC Australian guidelines
Hypertension	Maintain below 130/80 mmHg for all people with CKD.	See page 45 of the Handbook
Glycaemic control	Blood glucose levels (BGL): 6-8mmol/L fasting; 8-10 mmol/L postprandial. HbA1c: generally ≤53 mmol/mol (range 48-58); ≤7% (range 6.5-7.5). Needs individualisation according to patient circumstances (e.g. disease duration, life expectancy, important comorbidities, and established vascular complications).	See page 43 of the Handbook RACGP Managing Type 2 Diabetes in General Practice handbook Diabetes Australia
Albuminuria	50% reduction in urine ACR.	See page 69 of the Handbook
Lipids	Use statin or statin/ezetimibe combination in people ≥50 years with any stage of CKD, or in people <50 years with any stage of CKD in the presence of one or more of: coronary disease, previous ischaemic stroke, diabetes or estimated high cardiovascular risk (>15% over 5 years - cardiovascular risk can be assessed using www.cvdcheck.org.au)1. No target serum cholesterol level recommended.	KDIGO guidelines KHA-CARI guidelines National Vascular Disease Prevention Alliance RACGP National guide to preventive health assessment in Aboriginal and Torres Strait Islander people
Anaemia	100-115g/L. Prior to commencement of erythropoietin stimulating agent (ESA) a trial of iron supplementation maintaining: Ferritin >100 μg/L. Once ESA commenced, maintain: Ferritin 200-500 μg/L; TSAT 20-30%.	See page 70 of the Handbook
Potassium	K+ ≤6.0 mmol/L.	See page 75 of the Handbook
Immunisation	Influenza and invasive pneumococcal disease vaccination recommended for all people with diabetes and / or ESKD.	NHMRC guidelines

 

What’s new in the Handbook?

 

Treatment targets for the management of hypertension in people with CKD

Hypertension is both a cause and complication of CKD, and if left uncontrolled can lead to progression of kidney disease and increased risk of coronary heart disease and stroke.

The new treatment goal regarding blood pressure is for it to be maintained below 130/80 mmHg for all people with CKD, including those with albuminuria or diabetes.

Why worry about CKD?

 

New quick reference guide

A quick reference guide has been added to the handbook to provide a Summary of essential CKD information including CKD definitions, risk factors, detection algorithm, treatment goals and key clinical tips.

 

Chronic kidney disease hotspots

The prevalence of CKD is not evenly geographically distributed. Areas with significantly increased prevalence of chronic kidney disease (CKD hotspots) have been identified across Australia. Detailed information about your local area can be found at https://www.aihw.gov.au/reports/chronic-kidney-disease/geographical-variation-ckd/contents/contents

 

Sick day plan for management of acute kidney injury

Preventing acute kidney injury in CKD patients who are sick or dehydrated involves withholding medications that increase risk of decline in kidney function and medications that have reduced clearance and increase risk for adverse effects.

Mnemonic for drugs to be avoided on a sick day (SAD MANS):

• S sulfonylureas
• A ACE-inhibitors
• D diuretics
• M metformin
• A angiotensin receptor blockers
• N non-steroidal anti-inflammatory
• S SGLT2 inhibitors

 

Managing CKD in conjunction with other chronic conditions

In a primary care setting, it is very likely that individuals will have a CKD diagnosis that sits alongside one or more other chronic conditions. As CKD shares many treatment goals and management strategies with other common chronic diseases such as diabetes and cardiovascular disease, managing chronic conditions in conjunction with each other in a whole person approach leads to improved patient outcomes.

The 4th edition handbook includes a new section on the links between CKD, Diabetes and Hypertension which includes information on absolute cardiovascular risk assessment in CKD, treatment targets and medication advice for Diabetes and Hypertension in the presence of CKD, useful algorithms and blood pressure monitoring advice.

• CKD & Cardiovascular disease –absolute cardiovascular risk assessment in CKD
• CKD and Diabetes – treatment targets, medication advice
• Hypertension and CKD – treatment targets, medication advice

 

Kidney cysts

Simple cysts

Simple cysts are very common and usually asymptomatic. They do not cause kidney failure but may be associated with background CKD. Simple cysts can occur with advancing age and most are and do not require further investigation.

Indications for further review and investigation:

• Multiple cysts
• Bilateral multiple cysts
• Cysts with complex internal structure or solid components
• Inability to differentiate cysts from obstruction
• Past history of malignancy
• Symptoms from cyst (discomfort, haematuria, infection)

Polycystic kidney disease (PKD)

PKD is a group of chronic kidney diseases with formation of multiple cysts in the kidney. It is the most common inherited kidney disease and a common cause of CKD. Consider a PKD diagnosis if:

Age	Number of cysts shown on ultrasound
15-39 years	At least 3 in total
Aged 40-59 years	At least 2 in each kidney
Aged 60 years or older	At least 4 in each kidney

Autosomal dominant polycystic kidney disease (ADPKD)

Clinical management:

1. Assess if at high-risk for end stage kidney disease (ESKD)
2. Reduce kidney cyst growth and prevent eGFR decline and hypertension
3. Evaluate for other kidney complications
4. Discuss other problems

Tolvaptan has recently been listed on the Pharmaceutical Benefits Scheme (PBS) for the treatment of adults with early CKD (stage 2 to 3) and rapidly progressing ADPKD. Tolvaptan has been shown to slow the progression of cyst development and kidney disease in ADPKD.

 

Common Issues in CKD

 

Advice on the management of oedema and cognitive decline in CKD has been added to the extensive list of common issues in CKD

Oedema

Fluid retention and overload may become a problem with worsening CKD severity. Oedema is rarely caused by early stage CKD alone (except in nephrotic syndrome) and is more a feature of advanced stage CKD. Oedema most commonly manifests as ankle oedema, which may occur even if the patient is centrally volume depletes. Hypertension is common in fluid overload and the clinical assessment of oedema should include blood pressure and respiratory examination. Biomarkers such as brain natriuretic peptide (BNP) to assess fluid shifts may be unreliable in patients with CKD.

Oedema in patients with CKD may be caused by:

• CKD associated reduced water excretion and reduced urine output
• Nephrotic syndrome (urine protein loss and low blood albumin)
• Medications (amlodipine, nifedipine, steroids)
• Sodium retention and/or excess sodium intake
• Congestive cardiac failure
• Liver disease and low albumin
• Lymphoedema
• Vascular causes including DVT
• Dependent oedema (gravity, poor mobility)

Asymptomatic, mild ankle oedema does not usually require treatment and can instead be managed conservatively by raising legs, using stocking and moderate sodium restriction. Mild diuretic therapy with loop and thiazide diuretics should be used for treating ankle oedema only after assessment of volume status has occurred. Pulmonary oedema will usually warrant diuretic therapy and can require hospital care. In the later stages of CKD, patients may experience diuretic resistance and dosage may need to be increased. Refractory oedema in advanced CKD is usually an indication to commence dialysis.

Cognitive decline

Cognitive impairment is common in people with CKD and prevalence increases with CKD severity. It is an important factor when patients are approaching ESKD as it will influence treatment choices and decision making. CKD can affect patient’s global cognition, attention, memory and executive functions. CKD is a risk factor for accelerated aging and double the risk for physical impairment, cognitive dysfunction and frailty in those >70 years. Screen CKD patients for cognition using the Mini Mental State Examination (MMSE) and ensure consideration of patient safety, medication adherence, risk of delirium and association with depression.

Whole of practice approach to CKD care

Using a whole of practice approach in the treatment of CKD maximises the opportunity for best practice to occur. Identification of a clinical lead, clinical governance, correct coding of CKD and implementation of e-health will all impact outcomes.

The role of the GP

GPs are crucial in their ability to sustain an ongoing relationship with the patient and their family. GPs have continuing responsibility for the patient’s primary care including responding appropriately to new symptoms, co-developing management plans, providing appropriate vaccinations and screening for developing problems and comorbidities.

The role of the primary health care nurse

Primary health care nurses work collaboratively with the GP in providing best practice care for people with CKD and are pivotal in the identification of those at risk of CKD, supporting patient self-management strategies, providing the patient with ongoing education and support and facilitating patient-centred care planning.

 

Self-management and behavioural change in CKD

Behaviour change is a useful strategy in chronic disease management. Health professionals should consider offering health coaching to assist the patient in self-reflection regarding lifestyle behaviour strategies that would assist in managing their condition. Lifestyle modification should be considered as the first line of management for CKD patients. The implementation of lifestyle changes can have a positive effect on the outcome of CKD and delay the progression of the disease.

 

Updates to current recommendations

There have also been a range of important updates throughout the handbook including updates to the medication considerations in CKD section, and amended information for many of the common issues in CKD.

 

Key resources

Chronic Kidney Disease (CKD) Management in Primary Care (4th Edition).

Click here to view full text.

Read more about the changes:

• New treatment targets for the management of hypertension in people with CKD (maintain blood pressure below 130/80mmHg for anyone with CKD)
  Page 45
• New quick reference guide
  Pages 6-13
• Kidney disease hotspots – are you in one?
  Page 17
• New sick day plan for management of acute kidney injury
  Pages 53-55
• New information on managing CKD in the presence of diabetes and cardiovascular disease
  Pages 41-42
• New section on the management of kidney cysts
  Pages 58-59
• New information on the management of oedema and cognitive decline in CKD
  Pages 71 and 77
• Expanded information on ‘whole of practice approach’ to CKD care
  Pages 34-35
• Expanded information on self-management and behavioural change in CKD
  Page 35

Further information and resources

• Kidney Health Australia
  
  • Fact Sheets
  • Living with Kidney Failure book
  • CKD Go! App – all the best bits of this handbook in a free app (available on your app store)
  • Kidney Helpline (free-call 1800 454 363 | kidney.helpline@kidney.org.au)
• KHA CARI Guidelines

 

References

1. Chronic Kidney Disease (CKD) Management in Primary Care (4th edition). Kidney Health Australia, Melbourne, 2020.