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Managing Chronic Kidney Disease in Primary Care

2014

A National Consensus Statement

Citation: Ministry of Health. 2014. Managing Chronic Kidney Disease in Primary Care: A National Consensus Statement. Wellington: Ministry of Health.

Published in December 2014
by the
Ministry of Health
PO Box 5013, Wellington 6145, New Zealand

ISBN 978-0-478-44476-6 (online)
HP 6109

This document is available at www.health.govt.nz                                                                                

Executive summary

  1. The purpose of this National Consensus Statement is to articulate best practice in the identification and management of chronic kidney disease (CKD) in primary care. It is intended as a guide for clinicians and managers in both funder and provider organisations.

 

Detection

  1. To detect and manage chronic kidney disease (CKD), it is necessary to have systematic screening in primary care, linked with the current cardiovascular (CVD) and diabetes screening programme. This screening would involve addingserum creatinine and urinary albumin:creatinine ratio to the current laboratory tests in cases where they have not been otherwise documented. High-risk groups require earlier assessment.
  2. CKD should be classified from stage 1 to 5 and as stable or progressive.

 

Management

  1. People with stable CKD stages 3–4 are at > 20 per cent five-year CVD risk (with diabetes) or > 15 per cent five-year CVD risk (without diabetes). They need appropriate CVD risk management.
  2. Target blood pressure is 140/90 or less without proteinuria or 130/80 or less with proteinuria.
  3. Blood pressure management should start with an ACE inhibitor or angiotensin receptor blocker (unless contraindicated).
  4. People with progressive CKD stages 3–4 (rate of loss of GFR > 5 ml/min/year) have even higher CVD risk and a much higher risk of developing renal failure with need for dialysis or transplant. They must be intensively managed to reduce risk, which involves weekly or fortnightly risk factor management and review until stable. This approach could involve integrating nurse-led clinics into Long Term Conditions Management Programmes.
  5. The great majority of patients, particularly those with stable stage 3 CKD or who are older (> 75 years) with early stable stage 4 CKD, can be fully managed in primary care. Note that prescribing of medication should be carefully considered.

 

Enablers/monitoring

  1. Software-based decision support, audit and recall systems for best practice are part of best practice in the management of CKD.

 

Introduction

 

Chronic kidney disease (CKD) was identified in 2008 as an important health issue by the National Renal Advisory Board working in conjunction with Ministry of Health. It has been defined in the scoping paper entitled New Zealand’s Renal Services: Towards a national strategic plan. (1)

The reasons for this initiative included the:

  1. rising incidence and prevalence of end stage kidney disease (ESKD)
  2. need to improve identification and management of CKD in primary care
  3. need for effective national screening of at-risk patient groups
  4. need for broad implementation of patient-centred strategies in primary care to manage most patients with CKD.

 

The Ministry of Health supported four pilot projects running over two years that used innovative approaches to electronic screening and referral for CKD, and nurse-led clinics in primary care focused on intensive management of CKD.

The results of these pilot projects and a separate randomised controlled trial (DEFEND, undertaken in Auckland with Māori and Pacific patients with diabetes and CKD) led to a National Consensus conference on CKD held at Matakana in 2013.

Participants included diabetes specialists, nephrologists (renal physicians), family practitioners, nurses from primary and secondary care and Ministry of Health personnel.

This document has been prepared by the CKD Core Work Group. It summarises the conclusions and recommendations emerging from this consensus meeting. Its purpose is to articulate best practice in the identification and management of chronic kidney disease (CKD) in primary care. It is intended as a guide for clinicians and managers in both funder and provider organisations.

 

The classification of CKD

Chronic kidney disease is a general term for chronic disorders that affect kidney structure and function. Complications from CKD may in time affect all organ systems. However, most people with mild or moderate CKD have no symptoms.

CKD is classified using the criteria of the Kidney Disease Improving Global Outcomes Foundation (KDIGO) CKD Consensus Consortium (Figure 1). The classification is independent of the underlying cause of the kidney disease. Each stage is characterised by a glomerular filtration rate (GFR) range. The GFR is an estimate of kidney function based on serum creatinine as measured by the laboratory.

Patients in stages 1 and 2 CKD have documented kidney disease (eg, diabetic nephropathy or polycystic kidney disease) and are sub-classified by GFR. Patients in stages 3–5 have reduced GFR on which the classification is based. Because GFR declines in the overall population by 1 ml/minute/year, many elderly patients have reduced GFR and so meet the criterion for CKD stage 3. Most of these patients, however, do not show any evidence of active or structural kidney disease. In such cases, a kidney biopsy is likely to reveal sclerotic changes affecting renal vessels, glomeruli and interstitium (arteriolonephroscerosis) which might be described as ageing-related.

Table 1: CKD classification and prognostic risk from the KDIGO CKD Consensus Consortium (2)

 

Prognosis of CKD by GFR
and Albuminuria Categories:
KDIGO 2012

Persistent albuminuria categories
Description and range

A1

Normal to mildly increased

< 30 mg/g
< 3 mg/mmol

A2

Moderately increased

30–300 mg/g
3–30 mg/mmol

A3

Severely increased

> 300 mg/g
> 30 mg/mmol

GFR categories (ml/min/1.73 m2)
Description and range

G1

Normal or high

≥ 90

 

 

 

G2

Mildly decreased

60–89

 

 

 

G3a

Mildly to moderately decreased

45–59

 

 

 

G3b

Moderately to severely decreased

30–44

 

 

 

G4

Severely decreased

15–29

 

 

 

G5

Kidney failure

< 15

 

 

 

 

Green: low risk (if no other markers of kidney disease, no CKD); Yellow: moderately increased risk; Orange: high risk; Red: very high risk.

 

 Risks of CKD

CKD is associated with increased cardiovascular (CVD) and cerebrovascular risk and premature death. The presence of albuminuria is a marker of increased CVD risk as well as renal injury.

Table 2 Pooled analysis showing relative risk controlled for multiple co-variates from the CKD Consensus Consortium (1)

 

All-cause mortality

 

Cardiovascular mortality

 

ACR
< 10

ACR
10–20

ACR
30–299

ACR
≥ 300

 

 

ACR
< 10

ACR
10–20

ACR
30–299

ACR
≥ 300

eGFR
> 105

1.1

1.5

2.2

5.0

 

eGFR
> 105

0.9

1.3

2.3

2.1

eGFR
90–105

Ref

1.4

1.5

3.1

 

eGFR
90–105

Ref

1.5

1.7

3.7

eGFR
75–90

1.0

1.3

1.7

2.3

 

eGFR
75–90

1.0

1.3

1.6

3.7

eGFR
60–75

1.0

1.4

1.8

2.7

 

eGFR
60–75

1.1

1.4

2.0

4.1

eGFR
45–60

1.3

1.7

2.2

3.6

 

eGFR
45–60

1.5

2.2

2.8

4.3

eGFR
30–45

1.9

2.3

3.3

4.9

 

eGFR
30–45

2.2

2.7

3.4

5.2

eGFR
15–30

5.3

3.6

4.7

6.6

 

eGFR
15–30

14

7.9

4.8

8.1

 

Note: ACR is in North American units. A microalbuminuria to urine albumin/creatinine ratio of 3–30 mg/mmol (the microalbuminuria range) is equivalent to 30–299 in North American units.

Numbers of people with CKD

 

In New Zealand at the end of 2012, there were 2469 dialysis patients and 1520 successfully transplanted patients.(3) During that year, 513 commenced dialysis or had a pre-emptive kidney transplant. The number of treated dialysis patients has risen steadily throughout the history of this treatment. For example, in 2000 there were 1336 patients on dialysis compared with 2469 at the end of 2012, representing an increase of 84 per cent in 12 years. About half of all dialysis patients have diabetes as a primary cause. The cost to the health care system of dialysis for an individual ranges from $30,000 to $60,000 per year.

Currently in New Zealand the number of adults with CKD is unknown. According to data from elsewhere, including the USA, European and Asian countries, there is a prevalence of 7–10 per cent of the adult population. Assuming a prevalence of 7 per cent, there would be about 210,000 adult New Zealanders with CKD. However, fewer than 2 per cent of these will ultimately require renal replacement therapy (dialysis and/or kidney transplantation). In contrast, most are at increased risk for cardiovascular disease and/or death.

High-risk ethnic groups

 

Māori, Pacific and Indo Asian peoples have much higher rates of diabetes, CKD and ESKD than other ethnic groups in New Zealand. Achieving the early detection and management of diabetes and CKD for people of these ethnicities is a significant challenge for our health system.

It is necessary for health teams to establish relationships with Māori, Pacific and Indo Asian peoples as individuals, whānau, families and communities. Developing these relationships might include working with leaders of churches or marae. Long-term relationships, not only with individuals but also on a collective basis, underpin all successful long-term care. Without them, health teams will fail to engage with those individuals and families most in need.

Detection in primary care

CKD is usually first identified following tests arranged by primary care clinicians. An important challenge in primary care is to identify, and then carefully manage, the minority with progressive CKD. Although the average rate of loss of GFR with age is about 1 ml/min/year, patients with progressive CKD may lose kidney function at much faster rates, often as high as 10–20 ml/min/year.

Risk factors for CKD

 

Risk factors for CKD are:

Screening everyone with a single demographic risk factor for CKD as an independent clinical activity is not feasible in primary care. A realistic alternative is to test those identified according to their risk of CKD as part of a CVD risk assessment or diabetes check.

The individual’s risk factors for CKD should be considered when deciding whether to arrange screening for CKD with a serum creatinine (and eGFR) and urine ACR.

Management in primary care

 

It is now clear that CKD needs to be addressed under the umbrella of better management of long-term conditions in primary care. Many patients can be fully managed in primary care but, for a minority, management requires discussion with renal services for advice and further management. An important focus of secondary renal and diabetes services should be to work innovatively together with primary care to ensure that all clinicians are well supported in their provision of optimal renal care.

Guidelines for the management of CKD are well established. However, implementation of best practice for CKD in primary care settings is challenging because:

 

Goals for best practice in managing CKD

 

 

The role of primary care

As people age, GFR slowly falls to the point that, by the age of 70 years, some 30 per cent of the population could be classified as having CKD. However, most of these individuals do not have progressive CKD and further loss of renal function is slow. In contrast, those with diseases such as diabetic nephropathy can lose kidney function at a rate of 10–20 ml/min/year and rapidly progress towards ESKD.

Primary care has an important role in distinguishing between:

 

The great majority of patients, particularly those with stable stage 3 CKD or who are older (> 75 years) with early stable stage 4 CKD, can be fully managed in primary care, taking into account their age and whether they have stable or progressive CKD.

Recommended management practice

 

–    blood pressure measurement and optimisation (follow-up may be needed every two to four weeks in the early stages to achieve optimal blood pressure as noted above). Many patients require two or three anti-hypertensive agents, and advice on sodium restriction to < 100 mmol/day is essential for most)

–    laboratory measures of serum creatinine/eGFR and urine albumin/creatinine (or protein/creatinine) ratio every three months and after introduction of ACE inhibitors/ ARBs or diuretics)

–    additional laboratory monitoring as indicated by the stage of CKD (4).

Referral to specialist services

 

Most DHBs offer indications for referral to renal (nephrology) and/or diabetes services. See Kidney Health New Zealand’s Chronic Kidney Disease Management in General Practice (5) for additional guidance.

Refer patients for:

Where primary care clinicians are uncertain about management or referral, it is highly recommended that they use telephone consultations and/or ‘virtual’ referrals.

Examples of implementing best practice in CKD management in primary care

Recent pilot projects and the DEFEND randomised controlled trial (6) have demonstrated the effectiveness of complementary strategies to implement improved management of CKD in primary care and collaboration with secondary care. In particular:

Key enablers in CKD management

CKD can only be effectively managed in primary care as one aspect of the management of the range of long-term conditions. Primary care clinicians can easily incorporate the identification of CKD into CVD risk assessment and diabetes checks

To manage CKD effectively, primary care practices need suitable electronic support (see Appendix 1), including:

Nurse-led clinics for people with long-term conditions can undertake intensive management of people identified at high risk of progressive CKD (see Appendix 2). To manage CKD in primary care, practice nurses need to be able to work to their scope of practice. This requires:

 

Key stakeholder groups in CKD management

Improving care of people with CKD in primary care involves action from a range of groups in the health sector.

References

 

1.       National Renal Advisory Board. 2006. New Zealand’s Renal Services: Towards a national strategic plan. Wellington: National Renal Advisory Board.

 

2.       Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. 2013. KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney International Supplements 3(1): 1–150.

 

3.       Australia and New Zealand Dialysis and Transplant Registry. 2013. Summary of Australia and New Zealand Dialysis and Transplantation 2012. URL: www.anzdata.org.au/anzdata/AnzdataReport/36thReport/2012_Summary_v1.pdf (accessed 11 November 2014).

 

4.      Kidney Health Australia. 2005–2013. Caring for Australasians with Renal Insufficiency (CARI): CKD Guidelines. URL: www.cari.org.au/CKD/ckd_guidelines.html (accessed 11 November 2014).

 

5.       Kidney Health New Zealand. 2014. Chronic Kidney Disease Management in General Practice. URL: www.kidneys.co.nz/resources/file/ckd_management_in_general_practice._2014_version.pdf (accessed 11 November 2014).

 

6.      Hotu C, Bagg W, Collins J, et al. 2010. A community-based model of care improves blood pressure control and delays progression of proteinuria, left ventricular hypertrophy, and diastolic dysfunction in Maori and Pacific people with type 2 diabetes and chronic kidney disease: a randomised controlled trial. Nephrology, Dialysis and Transplant 25(10): 3260–66.

CKD Core Work Group

 

John Collins, Renal Physician, Auckland DHB

 

Ailsa Jacobson, Senior Advisor, Ministry of Health

 

Nick Polaschek, Senior Project Manager, Ministry of Health

 

Helen Rodenburg, General Practiioner, National Director Long Term Conditions

 

Rachael Walker, Renal Nurse Practitioner, Hawke’s Bay DHB

Appendix 1: Using software for CKD management in primary care

 

General principles for any software to be used for CKD management in primary care

 

An electronic decision support pathway for best practice management of CKD must:

 

Electronic desktop tool available for CKD management in primary care

The electronic desktop tool developed by the Best Practice Advocacy Centre (BPAC) to manage CKD is available free to primary care practices nationwide.

The tool is a clinical pathway, using a best practice approach informed by specialist renal expertise, including:

 

To be used successfully, such an electronic system needs to fit into current general practice work patterns through:

Challenges to implementation

Given electronic desktop tools for CKD management are now available, some of the challenges to implementation are to:

Appendix 2: Nurse-led clinics to manage high-risk CKD patients

General principles for nurse-led clinics in CKD management

In this strategy for best-practice CKD management, a primary care nurse manages a group of high-risk CKD patients:

During the clinics the nurse oversees the management of these high-risk CKD patients by:

To be used successfully, the nurse-led clinic needs to fit into current general practice work patterns through:

Successful trial of one model of nurse-led care

In one successful model of nurse-led care, nurses have supervised community health workers who visit patients at home or work to encourage them to adhere to their medication and who adjust blood pressure medication according to an algorithm. This model was successfully trialled in Auckland in the DEFEND trial. (6)

Challenges to implementation

Given the current configuration of primary and specialist care, some of the challenges to implementation are to

Contributors

 

Janine Bycroft                   Medical Director Health Navigator

 

Rachael Calverley             Director of Nursing and Workforce Development Waitemata PHO

 

John Collins                      Renal Physician Auckland DHB

 

Tim Cundy                        Professor of Medicine University of Auckland

 

Paul Drury                         Clinical Director, Auckland Diabetes Centre, Chair National Diabetes Service Improvement Group

 

Maggie Fisher                   Diabetes Physician Waikato DHB

 

Carmel Gregan-Ford         Education Manager Kidney Health New Zealand

 

Ailsa Jacobson                  Senior Advisor Ministry of Health

 

Tim Kenealy                      Associate Professor of Integrated Care, University of Auckland

 

Murray Leikis                    Renal Physician Capital and Coast DHB

 

Hwyel Lloyd                      Chief Medical Adviser, BPAC

 

Kelvin Lynn                       Medical Director Kidney Health New Zealand

 

Donna McArley                 Western Bay of Plenty PHO

 

Fifita McReady                 Diabetes Nurse Tongan Health Society

 

Lois Nikolajenko               Clinical Nurse Specialist Diabetes Primary Health Care
MidCentral DHB

 

Nick Polaschek                 Senior Project Manager Ministry of Health

 

Helen Rodenberg              National Clinical Director Long Term Conditions Ministry of Health

 

Tracey Saweirs                  Renal Nurse Specialist Northland DHB

 

Walaa Saweirs                   Renal Physician Northland DHB

 

Ian Simpson                      Renal Physician

 

Sandy Speedy                   Renal Nurse Specialist Auckland DHB

 

Jasmine Tan                     Jasmine Tan, Diabetes Fellow, Auckland Diabetes Centre

 

Chrissy Taylor                   Renal Nurse Specialist Auckland DHB

 

Murray Tilyard                  Professor General Practice University of Otago CEO BPAC

 

Villi Tutone                       Renal Physician Counties Manukau DHB

 

Curtis Walker                    Physician MidCentral DHB

 

Miranda Walker               Diabetes Nurse Specialist Capital and Coast DHB

 

Rachael Walker                Renal Nurse Practitioner Hawkes Bay DHB