MBBS(hons), BSc (hons), MRCP(UK), FRACP, PhD
www.melbournenephrologist.com
Dr Matthew Davies
Nephrologist & General Physician
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The Kidney Health Australia Handbook provides a comprehensive overview of the management of CKD in primary care. The recommendation to use aspirin as primary prophylaxis is controversial (I, personally, disagree with it), but otherwise I think these guidelines provide an excellent guide to management of CKD.
The UK National Institute for Clinical Excellence (NICE) guidelines are another great resource for evidence based investigation and management of kidney disease in primary care. They include information on areas including who and how to screen for CKD, how frequently to monitor patients with CKD and who to refer on to a specialist. These guidelines are largely applicable to an Australian population, with the exception of measurement of Cystatin eGFR, which is not routinely available here.
Links to Patient Education Resources are found here:
The Importance of Proteinuria in Predicting Outcomes
Symptom Management
As well as helping to determine the cause of CKD, it is important to remember the significance of proteinuria in predicting progression of chronic kidney disease and increasing cardiovascular risk.
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The charts to the right demonstrate the increased risk of cardiovascular and all cause mortality with falling GFR, and the further increase, at all stages of CKD, with the presence of micro- and macroalbuminuria.
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The colour coded table below gives a guide to the risk of progressive renal impairment in patients with different stages of CKD, in the presence of varying degrees of albuminuria (red = high risk), and outlines the goals of management based on the different risk categories.
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Blood Pressure Targets:
This is a guide I wrote for patients to help with managing symptoms that are common in patients with kidney disease such as itch, dry mouth and restless leg syndrome. It may also be useful for doctors to help with providing advice for symptom management, and can be printed and given to patients.
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Drawn from a combination of guidelines (including KDIGO, ADA, NICE, CHEP, ESH and JNC Guidelines), these are the targets I generally recommend:
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Not diabetic, CKD with no albuminuria: Clinic BP <140/90 mmHg
Diabetic, CKD with no albuminuria: Clinic BP <140/80 mmHg
CKD with albuminuria (inc microalb): Clinic BP <130/80 mmHg
No CKD, age < 80: Clinic BP <140/90 mmHg
No CKD, age > 80: Clinic BP < 150/90 mmHg
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Avoid lowering diastolic BP to <55mmHg, or <60mmHg in those with ischaemic heart disease
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* Home blood pressure targets are 5/5mmHg lower than clinic BP targets
* 24 hour BP targets are 10/5 mmHg lower than clinic BP targets, and there is some evidence that restoring normal diurnal variation improves outcomes.
Lipid Management in CKD
I recommend following the KDIGO guidelines recommendations for lipid management in CKD. KDIGO (Kidney Disease: Improving Global Outcomes) are a large international body who produce guidelines on various aspects of kidney disease management, which are generally considered the gold-standard guidelines among nephrologists.
It is important to remember that CKD is an independent risk factor for cardiovascular disease, and is not incorporated into traditional CV risk calculators, which therefore may underestimate risk in the CKD population. Statins have been clearly shown in well conducted RCT's to reduce CV events in patients with all stages of CKD, except for patients on dialysis.
KDIGO recommend treatment with a statin for:
(1) All patients with CKD over the age of 50 - all these patients will have an estimated 10 year CV risk of over 10%
(2) Patients with CKD under the age of 50 who have diabetes, ischaemic heart disease, cerebrovascular disease, or a 10 yr CV risk of over 10%
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Following a decision to treat, the following doses can be used:
- eGFR>60ml/min/1.73m2: any dose licensed for use in general population
- eGFR<60ml/min/1.73m2: Simvastatin 40mg, Atorvastatin 20mg, Rosuvastatin 10mg
NOTE - Statin doses above these have not been proven to be safe for use in patients with CKD3-5 (ie eGFR<60).
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Fibrates have not been proven to reduce CV events in patients with CKD, and the safety of combination treatment of fibrates and statins has not been adequately tested in patients with reduced GFR. I therefore generally recommend against the use of fibrates in the CKD 3-5 population.
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The KDIGO guidelines advocate for a 'fire and forget' approach to lipid management in CKD, that is not repeating lipid levels after a statin has been commenced.
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You can read a commentary I wrote on the KDIGO guidelines here:
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The full guidelines are available here:
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