A multidisciplinary panel of healthcare practitioners have developed four practical and actionable recommendations to improve the management of chronic kidney disease. Find out what they came up with.
A set of new treatment recommendations for chronic kidney disease covers tips for both screening and management.
Chronic kidney disease is a growing public health concern in Australia. The Australian Institute of Health and Welfare reported that over two million people were living with CKD in 2021, placing a significant personal and economic cost on families and the wider nation.
In an attempt to counteract the growing challenge of CKD, a multidisciplinary group of Australian clinicians have put their heads together and developed a set of practical recommendations for treating patients with CKD that are specific to the Australian population.
“The growing burden of CKD in Australia underscores the urgent need for standardised, evidence-based strategies that integrate multidisciplinary care models and leverage emerging therapies,” the authors wrote in the Internal Medicine Journal.
Eight healthcare professionals from across the country (two nephrologists, two cardiologists, two endocrinologists and two GPs) were invited to participate. Each participant was asked to develop at least one recommendation that would improve the standard of care for patients with CKD.
The group of eight practitioners came up with 21 recommendation statements, which were whittled down to nine unique recommendations after similar statements were combined. Each recommendation was discussed by the group and then voted on.
A consensus was defined as at least 75% of participants agreeing with the statement. Five of the nine recommendations achieved a consensus, although one was removed as it did not follow GRADE guidance on good or best practice statements.
Both uACR and eGFR should be assessed regularly in patients at increased CKD risk
The first recommendation related to screening for CKD, as up to 90% of kidney function can be lost before patients begin showing symptoms of CKD. eGFR and uACR are two of the three common screening approaches used in Australia (the third being blood pressure), and when taken together, can be used as an insightful method of estimating a patient’s risk of CKD and starting the appropriate treatment.
The authors recommended individuals with an increased risk of developing CKD (e.g., established or family history of CVD, over 50 years of age, obesity, diabetes, hypertension or smoking) should have their eGFR and uACR measured every one to two years. Aboriginal and Torres Strait Islander peoples aged 18 years and older should be screened every year.
The combination of eGFR and uACR levels can then be applied to the Kidney Disease: Improving Global Outcomes (KDIGO) CKD heatmap to determine how many times kidney function should be assessed each year. Patients with a low risk of CKD should be screened once a year, increasing to at least four times per year in patients at a very high risk of CKD.
Most patients with CKD can be managed in primary care, with referral when required
The expert panel felt that primary care practitioners (including GPs, nurses, pharmacists and allied health practitioners) were “uniquely positioned” to support patients with CKD and should therefore assess patients as per the previous recommendation in the first instance.
After the patient has been diagnosed, practitioners should consult the Kidney Health Australia CKD Handbook and determine a treatment plan based on these results.
“This handbook also recommends that patients be referred to a nephrologist where there is a rapidly declining eGFR (>15% over three months) and or signs of acute nephritis (oliguria, glomerular haematuria, acute hypertension and oedema); eGFR <30 mL/min/1.73 m2; sustained decrease in eGFR of 25% or more within 12 months OR a sustained decrease in eGFR of 15 mL/min/1.73 m2 per year; persistent uACR ≥30 mg/mmol; blood pressure remains difficult to treat despite ≥3 blood pressure agents [or] additional reasons for a referral to a nephrologist exist (e.g. youth, family history or Aboriginal and Torres Strait Island heritage),” the authors noted.
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Ensure all cardiometabolic risk factors are assessed and managed appropriately
“The interconnection between the kidney, CV and endocrine systems means that traditional cardiometabolic risk factors, including hypertension, insulin resistance/diabetes, dyslipidaemia, prior acute kidney injury/disease, heart failure and smoking, are highly prevalent in CKD patients and contribute significantly to both CV and kidney disease progression and worse outcomes,” the authors wrote.
As a result, disease in one of the cardio-renal-metabolic systems should prompt healthcare professionals to check for disease in the other systems. For example, patients with heart failure should also have their uACR, HbA1c and lipids checked. Similarly, individuals with an eGFR under 45 should commence lipid- and blood-pressure lowering therapies.
With respect to other cardiometabolic risk factors, clinicians should aim for an LDL cholesterol level under 1.8mmol/L, a HbA1c level between 6.5% and 8% and a blood pressure under 130/80mmHg. Patients who smoke should aim to quit as soon as possible.
For patients with diabetic kidney disease, consider the four pillars of therapy
Pharmacological advances have occurred in most parts of medicine, and treatments for kidney disease are no exception. The authors encourage the use of a multi-pronged approach for the management of diabetic kidney disease, as different medications target different aspects of disease pathogenesis. The following approach was recommended:
- Patients with hypertension and albuminuria should be treated with angiotensin-converting enzyme inhibitors (ACEis) or renin-angiotensin system (RAS) inhibitors to reduce intraglomerular pressure and blood pressure.
- If patients are also being treated with other glucose-lowering agents, a sodium glucose cotransporter 2 inhibitor (SGLT2i) should be added to improve glycaemic control and restore tubuloglomerular feedback, reduce glomerular hyperfiltration and lower intraglomerular pressure.
- Patients with non-diabetic CKD should receive RASis and SGLT2is as a starting point.
- A non-steroidal mineralocorticoid receptor agonists (NsMRAs) can be added to the RASi and SGLT2i in patients with type 2 diabetes, CKD, and eGFR of at least 25, normal serum potassium concentration and albuminuria despite using a RASi.
- GLP1-RAs should be used in patients with type 2 diabetes and CKD who have not responded to metformin and SGLT2i treatment.
The four recommendations that did not achieve the desired consensus related to the expected side effects of therapy and how to manage them, when heart failure patients should be referred to a nephrologist, do’s and don’ts for CKD patients with heart failure and secondary prevention tips for patients with cardiovascular disease.
The authors noted that while other guidelines had been designed to support the management of CKD in Australia, each of the existing resources had their own shortcomings.
“International guidelines, such as those developed by KDIGO, provide a comprehensive evidence-based framework for CKD management but do not account for Australia’s unique healthcare setting,” they wrote.
“The Caring for Australians with Renal Impairment (CARI) guidelines offer recommendations tailored to the Australian setting but are due for an update, with the latest edition having been published in 2013.
“KHA’s ’Chronic Kidney Disease Management in Primary Care’ handbook provides current, Australian-specific guidance but is aimed at primary care practitioners and does not fully address the coordination required across primary, secondary and tertiary services.
“Our consensus recommendations provide an actionable framework tailored to Australia’s unique healthcare landscape, prioritising equity in access, patient-centred care and proactive management of comorbid conditions.
“By implementing these strategies, clinicians can improve patient outcomes, reduce CKD-related complications and help alleviate the socioeconomic strain of CKD on individuals and the healthcare system.”
