What’s new in the Chronic Kidney Disease Management in General Practice book?

There have been some important updates to the 2nd edition of Chronic Kidney Disease Management in General Practice.1 It aims to provide guidance and clinical tips to help identify, manage and refer chronic kidney disease in general practice settings. The recommendations contained in the book were formed from existing evidence-based clinical guidelines, current research and clinical consensus.

Latest changes

The latest changes to the book include:

Blood pressure targets

  • People with chronic kidney disease should be treated with blood pressure lowering medicines to maintain a blood pressure that is consistently <140/90 mm Hg.1
  • If albuminuria is present (urine albumin:creatinine ratio >3.5 mg/mmol in females and >2.5 mg/mmol in males) a consistent blood pressure <130/80 mm Hg should be achieved.1
  • All people with diabetes should maintain a consistent blood pressure <130/80 mm Hg.1

Chronic kidney disease staging

  • It is now recommended by Australian and international guidelines that the stages of chronic kidney disease be based on the combined indices of kidney function (measured or estimated GFR), kidney damage (albuminuria/proteinuria), and underlying diagnosis.1
  • Stage 3 CKD (eGFR 30–59 mL/min/1.73 m2) has been divided into Stage 3a (eGFR 45–59 mL/min/1.73 m2) and Stage 3b (eGFR 30–44 mL/min/1.73 m2), to more accurately reflect risk stratification.1
  • eGFR is now calculated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula as it more appropriately categorises individuals with comorbidities compared with the older Modified Diet in Renal Disease (MDRD) formula.1,2 This will make little or no difference to clinical practice.1

Testing for albuminuria

  • The 2012 Australasian Proteinuria Consensus Working Group recommends that the preferred method for the detection of albuminuria in people with and without diabetes is urinary albumin:creatinine ratio.1
  • Urinary albumin:creatinine ratio accurately predicts renal and cardiovascular risks in population studies, and a reduction in this ratio predicts renoprotective benefit in intervention trials.1
  • Dipstick test for protein in the urine is now no longer recommended for this purpose as their sensitivity and specificity is not optimal.1

eGFR and older people

  • The 2012 Creatinine Consensus Working Group recommends against the use of age-related decision points in adults.1
  • It is now known that an eGFR < 60 mL/min/1.73 m2 is very common in older people, but should not be considered physiological or age-appropriate. Dose reduction based on the presumption of impairment may result in sub-dosing in patients with normal kidney function.3
References
  1. Kidney Health Australia. Chronic kidney disease (CKD) management in general practice. 2nd edition. 2012. http://www.kidney.org.au//LinkClick.aspx?fileticket=vfDcA4sEUMs%3d&tabid=635&mid=1584 (accessed 30 May 2013).
  2. Levey AS, Stevens LA, Schmid CH, et al. A new equation to estimate glomerular filtration rate. Annals Int Med 2009;150:604–12.[PubMed]
  3. Bell JS, Blacker N, Leblanc VT, et al. Prescribing for older people with chronic renal impairment. Aust Fam Physician 2013;42:24–8.[PubMed]