Chronic kidney disease (CKD) has five stages of progression, with the first three stages (eGFR ≥30ml/min/1.73m2) usually being managed in primary care.
Approximately 1.7 million Australian (~1 in10) aged 18 years and older have indicators of CKD, with CKD responsible for 16% of all hospitalisations in Australia and contributing to over 11% of all deaths. The impact of kidney disease on lost productivity in Australia between 2020 and 2029 is predicted to amount to $141.3 billion in GDP.
The number of patients with end stage kidney disease (ESKD) also continues to expand and has become a major challenge for health systems globally, with 2.6 million people receiving renal replacement therapy in 2010 expected to grow to 14.5 million people needing renal replacement therapy by 2030.
Management of early CKD focuses on optimisation of cardiovascular risk factors, such as treating blood pressure to target and achieving tight glycaemic control in diabetics which also improves renal outcomes. Where appropriate, pharmacological therapies that have been demonstrated to slow the progression of CKD, namely renin-angiotensin system blockade, statins, GLP-1 receptor agonists and SGLT2 inhibitors (Dapagliflozin has recently been approved on the PBS for the management of proteinuric CKD: streamline authority 13230) should be instituted.
The Kidney Health Australia Chronic Disease (CKD) Management in Primary Care publication is an excellent resource to use when performing kidney health checks on individuals who have risk factors for CKD.
As the patient’s condition progresses to stage four and five (or for patients with CKD stage 3 that is rapidly progressing – e.g. a sustained annual loss of eGFR of ≥ 5ml/min/1.73m2/year), patients should ideally be referred to specialised nephrology services for further management.
In addition to continuing therapies to delay disease progression and adjusting medications that may accumulate or become harmful due to reduced clearance, discussions will commence to prepare the patient for transition to a renal replacement therapy, or supportive care.
In our unit this care is led by a multidisciplinary team, incorporating renal physicians, pre-dialysis and CKD educators, vascular access specialists, dietitians and diabetes educators to deliver a “one stop shop” to manage significant co-morbid medical conditions and to focus on efforts to improve quality of life.
Treatment options for ESKD patients include haemodialysis (HD), peritoneal dialysis (PD), transplantation and supportive care. People who choose PD carry this out at home, whereas HD is primarily performed in satellite dialysis units or in hospital in-centre units, although the number of patients doing home HD is growing. There is a major focus nationally and internationally on growing home therapy use (for appropriate patients) due to improved quality of life and significant cost savings for the health system.
A multidisciplinary model of care has become an important addition to the NHMS renal service and is delivered through a coordinated patient-centred clinic. This team helps guide patients from the pre-dialysis stage to renal replacement therapy. Coordination with primary care management plays a critical role and key areas under development to strengthen these relationships include:
- Opportunities to provide outreach into practices to discuss CKD management and shared care models.
- Opportunities for observerships within the renal unit.
- A combined standardised management plan format which enables easier communication between tertiary and primary health
- A focus on how we can manage those patients that have chosen a supportive care pathway.
The Sir Charles Gairdner Osborne Park Health Care Group Nephrology website provides comprehensive resources and information for patients and primary health providers.
Home therapies should be encouraged for those individuals who are able. They provide the patient with greater treatment flexibility, independence, responsibility and better quality of life. Several studies have now demonstrated that PD is at least as good or even better than HD in the first few years for patients who commence dialysis.
Key messages
- Chronic kidney disease is common with significant morbidity and economic cost
- A multidisciplinary approach including coordination with primary care enhances patient outcomes
- Encourage home therapies including peritoneal dialysis where possible.
– References are available on request
Author competing interests – nil
The Kidney Australia management booklet is available at kidney.org.au/uploads/resources