Guide: CKD guideline handbook update
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.
Definition of CKD
Algorithm for initial detection of CKD
Treatment goals for people with CKD
|Parameter||Treatment goal||For more info|
|Diet and nutrition||
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
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)
- Assess if at high-risk for end stage kidney disease (ESKD)
- Reduce kidney cyst growth and prevent eGFR decline and hypertension
- Evaluate for other kidney complications
- 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
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
- 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 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.
Chronic Kidney Disease (CKD) Management in Primary Care (4th Edition).
- New treatment targets for the management of hypertension in people with CKD (maintain blood pressure below 130/80mmHg for anyone with CKD)
- New quick reference guide
- Kidney disease hotspots – are you in one?
- New sick day plan for management of acute kidney injury
- New information on managing CKD in the presence of diabetes and cardiovascular disease
- New section on the management of kidney cysts
- 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
- Expanded information on self-management and behavioural change in CKD
- Kidney Health Australia
- KHA CARI Guidelines
- Chronic Kidney Disease (CKD) Management in Primary Care (4th edition). Kidney Health Australia, Melbourne, 2020.