1. RENAL BLOOD TESTS WHAT DO THEY MEAN, WHERE TO GO FOR WHAT TO DO

2. WHAT WE WILL COVER WHO TO SCREEN WHO TO SCREEN WHAT DO THE RESULTS MEAN WHAT DO THE RESULTS MEAN HOW TO CATEGORISE / CLASSIFY HOW TO CATEGORISE / CLASSIFY MANAGEMENT MANAGEMENT MONITORING MONITORING

3. CHRONIC KIDNEY DISEASE (CKD) SCREENING FOR CKD – RISK FACTORS SCREENING FOR CKD – RISK FACTORS AGE <60 YEARS AGE <60 YEARS DIABETES, CARDIOVASCULAR DISEASE, UROLOGICAL DISEASE DIABETES, CARDIOVASCULAR DISEASE, UROLOGICAL DISEASE FAMILY HISTORY OF KIDNEY DISEASE FAMILY HISTORY OF KIDNEY DISEASE HYPERTENSION HYPERTENSION SMOKING SMOKING OBESITY OBESITY ETHNICITY – MAORI, PACIFIC, INDO ASIAN (SAME AS CVRA COHORT) ETHNICITY – MAORI, PACIFIC, INDO ASIAN (SAME AS CVRA COHORT) NEPHROTOXIC DRUGS NEPHROTOXIC DRUGS ALBUMIN CREATININE RATIO (ACR), ESTIMATED GLOMERULAR FILTRATION RATE (e-GFR) AND MSU ALBUMIN CREATININE RATIO (ACR), ESTIMATED GLOMERULAR FILTRATION RATE (e-GFR) AND MSU

4. PROTIENURIA PROTIENURIA FACTORS AFFECTING URINARY PROTEIN EXCRETION INCREASES PROTEIN EXCRETION INCREASES PROTEIN EXCRETION STRENUOUS EXERCISE STRENUOUS EXERCISE POORLY CONTROLLED DM POORLY CONTROLLED DM HEART FAILURE HEART FAILURE UTI UTI ACUTE FEBRILE ILLNESS ACUTE FEBRILE ILLNESS UNCONTROLLED HYPERTENSION UNCONTROLLED HYPERTENSION HAEMATURIA HAEMATURIA MENSTRUATION MENSTRUATION PREGNANCY PREGNANCY DECREASES PROTEIN EXCRETION: DECREASES PROTEIN EXCRETION: ACEI/ARB ACEI/ARB NSAIDS NSAIDS

8. MANAGEMENT OF MICROALBUMINURIA Men = ACR >2.5mg/mmol AND 3.5mg/mmol AND 2.5mg/mmol AND 3.5mg/mmol AND <35mg/mmol* LOW SALT DIET LOW SALT DIET SMOKING CESSATION SMOKING CESSATION TARGET BP < 130/80 mmhg TARGET BP < 130/80 mmhg USE ACEI/ARB USE ACEI/ARB HBA1C < 55 mmol/mol HBA1C < 55 mmol/mol STATIN STATIN ASPIRIN ASPIRIN * Clinical Pathways can differ from Primary Care Handbook

9. GOALS OF MANAGEMENT OF CKD MEN = URINE ACR > 25 mg/mmol OR eGFR 35 mg/mmol OR eGFR 25 mg/mmol OR eGFR 35 mg/mmol OR eGFR < 45 ml/min/1.73m 2 INVESTIGATIONS TO EXCLUDE TREATABLE DISEASE INVESTIGATIONS TO EXCLUDE TREATABLE DISEASE REDUCE PROGRESSION OF KIDNEY DISEASE REDUCE PROGRESSION OF KIDNEY DISEASE REDUCE CVD RISK REDUCE CVD RISK EARLY DETECTION AND MANAGEMENT OF COMPLICATIONS EARLY DETECTION AND MANAGEMENT OF COMPLICATIONS AVOIDANCE OF NEPHROTOXIC MEDICATIONS OR VOLUME DEPLETION AVOIDANCE OF NEPHROTOXIC MEDICATIONS OR VOLUME DEPLETION ADJUSTMENT OF MEDICATION DOSES TO LEVELS APPROPRIATE FOR KIDNEY FUNCTION ADJUSTMENT OF MEDICATION DOSES TO LEVELS APPROPRIATE FOR KIDNEY FUNCTION APPROPRIATE REFERRAL TO A NEPHROLOGIST WHEN INDICATED APPROPRIATE REFERRAL TO A NEPHROLOGIST WHEN INDICATED * Clinical Pathways can differ from Primary Care Handbook

10. MONITORING OF CKD CLINICAL ASSESSMENT: CLINICAL ASSESSMENT: BLOOD PRESSURE BLOOD PRESSURE WEIGHT WEIGHT LABORATORY ASSESSMENT: LABORATORY ASSESSMENT: URINE ACR URINE ACR BIOCHEMICAL PROFILE INCLUDING UREA, CREATININE AND ELECTROLYTES BIOCHEMICAL PROFILE INCLUDING UREA, CREATININE AND ELECTROLYTES EGFR EGFR HBA1C (FOR PEOPLE WITH DIABETES) HBA1C (FOR PEOPLE WITH DIABETES) FASTING LIPIDS FASTING LIPIDS FULL BLOOD COUNT FULL BLOOD COUNT CALCIUM AND PHOSPHATE CALCIUM AND PHOSPHATE PARATHYROID HORMONE (6-12 MONTHLY IF EGFR < 45 ML/MIN/1.73M 2 ) PARATHYROID HORMONE (6-12 MONTHLY IF EGFR < 45 ML/MIN/1.73M 2 )

11. BLOOD PRESSURE REDUCTION CKD CAN CAUSE AND AGGRAVATE HYPERTENSION WHICH CAN CONTRIBUTE TO THE PROGRESSION OF CKD CKD CAN CAUSE AND AGGRAVATE HYPERTENSION WHICH CAN CONTRIBUTE TO THE PROGRESSION OF CKD REDUCING BLOOD PRESSURE TO BELOW THRESHOLD LEVELS IS ONE OF THE MOST IMPORTANT GOALS IN THE MANAGEMENT OF CKD REDUCING BLOOD PRESSURE TO BELOW THRESHOLD LEVELS IS ONE OF THE MOST IMPORTANT GOALS IN THE MANAGEMENT OF CKD TARGET BP < 140/90 MMHG IF NO PROTEINURIA PRESENT AND LESS AGGRESSIVE TARGET IN ELDERLY TARGET BP < 140/90 MMHG IF NO PROTEINURIA PRESENT AND LESS AGGRESSIVE TARGET IN ELDERLY ACE INHIBITOR OR ARB IS RECOMMENDED AS FIRST LINE THERAPY ACE INHIBITOR OR ARB IS RECOMMENDED AS FIRST LINE THERAPY MONITORING OF CREATININE AND POTASSIUM 5-10 DAYS AFTER STARTING AN ACE INHIBITOR OR ARB AND AFTER EACH DOSE INCREMENT MONITORING OF CREATININE AND POTASSIUM 5-10 DAYS AFTER STARTING AN ACE INHIBITOR OR ARB AND AFTER EACH DOSE INCREMENT COMBINED THERAPY OF ACE INHIBITOR AND ARB IS NOT RECOMMENDED COMBINED THERAPY OF ACE INHIBITOR AND ARB IS NOT RECOMMENDED MAXIMUM TOLERATED DOSES OF ACE INHIBITOR OR ARB ARE RECOMMENDED MAXIMUM TOLERATED DOSES OF ACE INHIBITOR OR ARB ARE RECOMMENDED HYPERTENSION MAY BE DIFFICULT TO CONTROL AND MULTIPLE (3-4) MEDICATIONS ARE FREQUENTLY REQUIRED HYPERTENSION MAY BE DIFFICULT TO CONTROL AND MULTIPLE (3-4) MEDICATIONS ARE FREQUENTLY REQUIRED NOTE: ACE INHIBITORS AND ARBS CAN CAUSE A REVERSIBLE REDUCTION IN GFR WHEN TREATMENT IS INITIATED. IF THE REDUCTION IS LESS THAN 25% AND STABILISES WITHIN TWO MONTHS OF STARTING THERAPY, THE ACE INHIBITOR OR ARB SHOULD BE CONTINUED. IF THE REDUCTION IN GFR EXCEEDS 25% BELOW THE BASELINE VALUE, THE MEDICATION SHOULD BE CEASED AND CONSIDERATION SHOULD BE GIVEN TO REFERRAL TO A NEPHROLOGIST FOR BILATERAL RENAL ARTERY STENOSIS

12. GLYCAEMIC CONTROL TARGET HBA1C < 55 mmol/mol TARGET HBA1C < 55 mmol/mol FOR PEOPLE WITH DIABETES, BLOOD GLUCOSE CONTROL SIGNIFICANTLY REDUCES THE RISK OF DEVELOPING CKD, AND IN THOSE WITH CKD REDUCES THE RATE OF PROGRESSION FOR PEOPLE WITH DIABETES, BLOOD GLUCOSE CONTROL SIGNIFICANTLY REDUCES THE RISK OF DEVELOPING CKD, AND IN THOSE WITH CKD REDUCES THE RATE OF PROGRESSION METFORMIN - MAX DOSE 2 G/DAY WHEN eGFR < 45 AND STOP WHEN eGFR < 30 METFORMIN - MAX DOSE 2 G/DAY WHEN eGFR < 45 AND STOP WHEN eGFR < 30 PLEASE NOTE THE INCREASING RISK OF HYPOGLYCAEMIC EVENTS IN STAGE 4/5 CKD. THERE IS POTENTIAL INCREASED EFFECT OF MEDICINES AS RENAL FUNCTION DETERIORATES SO CONSIDERATION AND CAUTION IS REQUIRED

13. LIPID LOWERING TREATMENTS TC:HDL RATIO < 4 TC:HDL RATIO < 4 LIPID-LOWERING TREATMENT SHOULD BE CONSIDERED WHERE APPROPRIATE FOR CVD RISK REDUCTION LIPID-LOWERING TREATMENT SHOULD BE CONSIDERED WHERE APPROPRIATE FOR CVD RISK REDUCTION CARE OF INCREASING RISK OF SIDE-EFFECTS, ESPECIALLY RHABDOMYOLYSIS CARE OF INCREASING RISK OF SIDE-EFFECTS, ESPECIALLY RHABDOMYOLYSIS

14. LIFESTYLE MODIFICATION CESSATION OF SMOKING CESSATION OF SMOKING WEIGHT REDUCTION WEIGHT REDUCTION LOW-SALT DIET LOW-SALT DIET PHYSICAL ACTIVITY PHYSICAL ACTIVITY MODERATE ALCOHOL CONSUMPTION MODERATE ALCOHOL CONSUMPTION ARE SUCCESSFUL IN REDUCING OVERALL CVD RISK

15. ABSOLUTE CARDIOVASCULAR RISK ASSESSMENT PATIENTS WITH MODERATE OR SEVERE CKD (URINE ACR > 25 mg/mmol IN MALES OR > 35 mg/mmol IN FEMALES OR e GFR 25 mg/mmol IN MALES OR > 35 mg/mmol IN FEMALES OR e GFR < 45 mL/min/1.73m 2 ) ARE THE HIGHEST RISK OF A CARDIOVASCULAR EVENT. THEY DO NOT NEED TO BE ASSESSED BY THE CARDIOVASCULAR RISK TOOL FOR THESE GROUPS, IDENTIFYING ALL CARDIOVASCULAR RISK FACTORS PRESENT WILL ENABLE INTENSIVE MANAGEMENT BY LIFESTYLE INTERVENTIONS (FOR ALL PATIENTS) AND PHARMACOLOGICAL INTERVENTIONS (WHERE INDICATED) FOR THESE GROUPS, IDENTIFYING ALL CARDIOVASCULAR RISK FACTORS PRESENT WILL ENABLE INTENSIVE MANAGEMENT BY LIFESTYLE INTERVENTIONS (FOR ALL PATIENTS) AND PHARMACOLOGICAL INTERVENTIONS (WHERE INDICATED) CONSIDER COMMENCING ASPIRIN FOR THOSE AT HIGH CVD RISK (ORANGE/RED RISK), THOSE WITH CKD 3B (eGFR 50 (ACR > 30) AND/OR/ESPECIALLY THOSE WHO HAVE HAD A MYOCARDIAL EVENT. SEE CKD MANAGEMENT IN GENERAL PRACTICE BY KIDNEY HEALTH AUSTRALIA/ANZSN/RACGP CONSIDER COMMENCING ASPIRIN FOR THOSE AT HIGH CVD RISK (ORANGE/RED RISK), THOSE WITH CKD 3B (eGFR 50 (ACR > 30) AND/OR/ESPECIALLY THOSE WHO HAVE HAD A MYOCARDIAL EVENT. SEE CKD MANAGEMENT IN GENERAL PRACTICE BY KIDNEY HEALTH AUSTRALIA/ANZSN/RACGP

20. COMMONLY PRESCRIBED DRUGS THAT MAY NEED TO BE REDUCED IN DOSE OR CEASED IN CKD ANTIVIRALS ANTIVIRALS BENZODIAZEPINES BENZODIAZEPINES COLCHICINE COLCHICINE DABIGATRAN DABIGATRAN DIGOXIN DIGOXIN EXENATIDE EXENATIDE FENOFIBRATE FENOFIBRATE GABAPENTIN GABAPENTIN INSULIN INSULIN LITHIUM LITHIUM METFORMIN (MAX DOSE 2 G/DAY EGFR 30-45 ML/MIN/1.73 M 2 AND STOP IF EGFR < 30 ML/MIN/1.73 M 2 ) METFORMIN (MAX DOSE 2 G/DAY EGFR 30-45 ML/MIN/1.73 M 2 AND STOP IF EGFR < 30 ML/MIN/1.73 M 2 ) OPIOID ANALGESICS OPIOID ANALGESICS SAXAGLIPTIN SAXAGLIPTIN SITAGLIPTIN SITAGLIPTIN SOTALOL SOTALOL SPIRONOLACTONE SPIRONOLACTONE SULPHONYLUREAS (ALL) SULPHONYLUREAS (ALL) VILDAGLIPTIN VILDAGLIPTIN

21. COMMONLY PRESCRIBED DRUGS THAT CAN ADVERSELY AFFECT KIDNEY FUNCTION IN CKD: NSAIDS AND COX-2 INHIBITORS NSAIDS AND COX-2 INHIBITORS BEWARE THE 'TRIPLE WHAMMY' OF NSAID/COX-2 INHIBITOR, ACE INHIBITOR AND DIURETIC (LOW DOSE ASPIRIN IS OKAY) WHICH CAN RESULT IN A POTENTIALLY SERIOUS INTERACTION, ESPECIALLY IF VOLUME- DEPLETED OR CKD IS PRESENT. ENSURE INDIVIDUALS ON BLOOD PRESSURE MEDICATION ARE AWARE OF THE NEED TO DISCUSS APPROPRIATE PAIN RELIEF MEDICATION WITH A GENERAL PRACTITIONER OR PHARMACIST. BEWARE THE 'TRIPLE WHAMMY' OF NSAID/COX-2 INHIBITOR, ACE INHIBITOR AND DIURETIC (LOW DOSE ASPIRIN IS OKAY) WHICH CAN RESULT IN A POTENTIALLY SERIOUS INTERACTION, ESPECIALLY IF VOLUME- DEPLETED OR CKD IS PRESENT. ENSURE INDIVIDUALS ON BLOOD PRESSURE MEDICATION ARE AWARE OF THE NEED TO DISCUSS APPROPRIATE PAIN RELIEF MEDICATION WITH A GENERAL PRACTITIONER OR PHARMACIST. RADIOGRAPHIC CONTRAST AGENTS RADIOGRAPHIC CONTRAST AGENTS AMINOGLYCOSIDES AMINOGLYCOSIDES LITHIUM LITHIUM CALCINEURIN INHIBITORS CALCINEURIN INHIBITORS

22. WHAT DO YOU KNOW? WHO TO SCREEN WHO TO SCREEN WHAT DO THE RESULTS MEAN WHAT DO THE RESULTS MEAN HOW TO CATEGORISE / CLASSIFY HOW TO CATEGORISE / CLASSIFY MANAGEMENT MANAGEMENT MONITORING MONITORING

23. INDICATIONS FOR REFERRAL TO A NEPHROLOGIST REFERRAL TO A SPECIALIST RENAL SERVICE OR NEPHROLOGIST IS RECOMMENDED: REFERRAL TO A SPECIALIST RENAL SERVICE OR NEPHROLOGIST IS RECOMMENDED: IF EGFR < 30 ML/MIN/1.73M 2 IF EGFR < 30 ML/MIN/1.73M 2 PERSISTENT SIGNIFICANT ALBUMINURIA (URINE ACR > 70 MG/MMOL) PERSISTENT SIGNIFICANT ALBUMINURIA (URINE ACR > 70 MG/MMOL) A CONSISTENT DECLINE IN EGFR FROM A BASELINE OF 5 ML/MIN/1.73M 2 OVER A SIX MONTH PERIOD WHICH IS CONFIRMED ON AT LEAST THREE SEPARATE READINGS) A CONSISTENT DECLINE IN EGFR FROM A BASELINE OF 5 ML/MIN/1.73M 2 OVER A SIX MONTH PERIOD WHICH IS CONFIRMED ON AT LEAST THREE SEPARATE READINGS) GLOMERULAR HAEMATURIA WITH MACROALBUMINURIA GLOMERULAR HAEMATURIA WITH MACROALBUMINURIA CKD AND HYPERTENSION THAT IS DIFFICULT TO GET TO TARGET DESPITE AT LEAST THREE ANTI-HYPERTENSIVE AGENTS. CKD AND HYPERTENSION THAT IS DIFFICULT TO GET TO TARGET DESPITE AT LEAST THREE ANTI-HYPERTENSIVE AGENTS. ANYONE WITH AN ACUTE PRESENTATION AND SIGNS OF ACUTE NEPHRITIS (OLIGURIA, HAEMATURIA, ACUTE HYPERTENSION AND OEDEMA) SHOULD BE REGARDED AS A MEDICAL EMERGENCY AND SHOULD BE REFERRED WITHOUT DELAY. ANYONE WITH AN ACUTE PRESENTATION AND SIGNS OF ACUTE NEPHRITIS (OLIGURIA, HAEMATURIA, ACUTE HYPERTENSION AND OEDEMA) SHOULD BE REGARDED AS A MEDICAL EMERGENCY AND SHOULD BE REFERRED WITHOUT DELAY. ALSO TAKE INTO ACCOUNT THE INDIVIDUAL'S WISHES AND COMORBIDITIES WHEN CONSIDERING REFERRAL. ALSO TAKE INTO ACCOUNT THE INDIVIDUAL'S WISHES AND COMORBIDITIES WHEN CONSIDERING REFERRAL. REFERRAL IS NOT NECESSARY IF: REFERRAL IS NOT NECESSARY IF: STABLE EGFR ≥ 30 ML/MIN/1.73M 2 STABLE EGFR ≥ 30 ML/MIN/1.73M 2 URINE ACR < 30 MG/MMOL (WITH NO HAEMATURIA) URINE ACR < 30 MG/MMOL (WITH NO HAEMATURIA) CONTROLLED BLOOD PRESSURE. CONTROLLED BLOOD PRESSURE. THE DECISION TO REFER OR NOT MUST ALWAYS BE INDIVIDUALISED. PARTICULARLY IN YOUNGER INDIVIDUALS THE INDICATIONS FOR REFERRAL MAY BE LESS STRINGENT. THE DECISION TO REFER OR NOT MUST ALWAYS BE INDIVIDUALISED. PARTICULARLY IN YOUNGER INDIVIDUALS THE INDICATIONS FOR REFERRAL MAY BE LESS STRINGENT.