Chronic kidney disease (CKD) is defined as:⁹

• an estimated or measured glomerular filtration rate (GFR) <60 mL/min/1.73m² that is present for ≥3 months with or without evidence of kidney damage
  or
• evidence of kidney damage with or without decreased GFR that is present for ≥3 months as evidenced by the following, irrespective of the underlying cause:
  • albuminuria
  • haematuria after exclusion of urological causes
  • structural abnormalities (eg on kidney imaging tests)
  • pathological abnormalities (eg renal biopsy).

CKD is classified into six stages depending on GFR; however, stage 2 requires evidence of kidney damage in addition to reduced GFR, whereas stages 3a-5 are defined on the basis of GFR alone.¹¹

CKD in itself is not a diagnosis. Attempts should always be made to identify the underlying cause of the disease.⁹

Many of the risk factors associated with CKD are modifiable, so those with risk factors or who have been diagnosed with CKD should be encouraged to make changes to their lifestyle to slow its progression. These should be individualised to the patient and may include encouragement and support to:¹¹

	cease smoking minimise exposure to environmental tobacco smoke
	exercise regularly, based on physical ability and medical history lose weight, if overweight or obese
	eat a balanced diet, rich in fruit, vegetables and dietary fibre consume the recommended daily intake of protein for adults The recommended daily intake of protein for an adult (ie 19-50 years old) is:3 0.75g/kg/day for woman (2 ½ serves) 0.84g/kg/day for men (3 serves) A standard serving size is one of:3 65 g cooked lean meats such as beef, lamb, veal, pork, goat or kangaroo (about 90-100 g raw) 80 g cooked lean poultry such as chicken or turkey (100 g raw) 100 g cooked fish fillet (about 115 g raw weight) or one small can of fish 2 large eggs 1 cup (150 g) cooked dried beans, lentils, chickpeas, split peas or canned beans (preferably with no added salt) 170 g tofu 30 g nuts, seeds, peanut or almond butter or tahini or other nut or seed paste (no added salt).
	limit dietary sodium intake to one teaspoon (6g) salt per day and avoid salt substitutes that contain high amounts of potassium
	consume a daily fluid intake of approximately 2-2.5L (including the fluid content of foods), depending on individual circumstances.

There is mixed evidence on the extent to which childhood renal disease contributes to high CKD rates in Aboriginal and Torres Strait Islander adults. However, given the high rate of CKD in Aboriginal and Torres Strait Islander adults, there may be opportunities to prevent the trajectory to end-stage renal disease through interventions starting in childhood. These include:

	routine urinalysis and BP surveillance for children with significant risk factors (ie obese/overweight, renal disease, congenital heart disease, strong family history and pre-pubertal and pubertal onset diabetes)11
	screening children living in areas with high rates of infectious skin diseases for scabies and impetigo annually and as the opportunity arises, and treating according to guidelines10
	considering imaging tests for children when they have their first urinary tract infection.10

In addition to lifestyle modifications, an angiotensin converting enzyme (ACE) inhibitor or angiotensin II receptor blocker (ARB) should be prescribed to lower blood pressure and protein excretion. Combination therapy of an ACE inhibitor and ARB is not recommended.⁹

ACE inhibitors and ARBs cause a reversible reduction in glomerular blood flow and GFR initially. If the reduction is less than 25% of the baseline value within two months of starting therapy, it should be continued (even though this may result in the patient being diagnosed with a later stage of CKD). If the reduction in GFR is more than 25% below the baseline value, the medication should be ceased and referral to a nephrologist should be considered (See Example).⁹

Example

For example, if the patient’s baseline value was 54 mL/min/1.73m and the GFR two months later was 48.6mL/min/1.73m² (10% reduction), you would continue this treatment. If the new GFR was 37.8mL/min/1.73m² (30% reduction), you would stop treatment and consider referral to a nephrologist.

Other medications may also be required to control hypertension, diabetes or other comorbidities. Regular review of all patient medications should therefore occur to identify and avoid combinations which may lead to potential nephrotoxicity (See Table 1 and Table 2).⁹ Patients taking an ACE inhibitor or ARB plus diuretic also need to avoid non-steroidal anti-inflammatory drugs (other than low-dose aspirin if indicated) as this can result in acute kidney injury.⁹

ACE inhibitors and ARBs may be temporarily discontinued during acute illness, but should be recommenced when the condition stabilises.⁹

Patients in stage 5 CKD should be given sufficient information regarding their condition and treatment options, including transplant or dialysis.⁹

Access to interpreters should always be offered where required to help patients manage their condition and minimise barriers to accessing care. Providing access to culturally appropriate patient resources is also important. See the Patient Information section of this course for some resources.

Australian guidelines recommend referral of patients with any of the indications in the image below to a specialist renal service or nephrologist.

[Click image to enlarge]

If you would like to do a short case study on this topic, you can enrol in the Closing the gap: Addressing chronic kidney disease in Aboriginal and Torres Strait Islander peoples activity on gplearning. Completion of the online activity is worth 2 CPD Activity points.

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Additional resources

Resources

• Department of the Prime Minister and Cabinet Aboriginal and Torres Strait Islander Health Performance Framework 2014 Report
• Australian Institute of Health and Welfare Indigenous health check (MBS 715) data tool
• Department of Health Medicare Health Assessment for Aboriginal and Torres Strait Islander People (MBS Item 715)
• Kidney Health Australia Salt and your kidneys
• RACGP Identification of Aboriginal and Torres Strait Islander people in Australian general practice
• RACGP Five steps towards excellent Aboriginal and Torres Strait Islander healthcare

Patient information

• Kidney Health Australia – Indigenous resources
• Kidney Health Australia – Resources for health professionals working with Aboriginal and Torres Strait Islanders
• Kidney Health Australia – Resources library

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References

1. Australian Government – Australian Institute of Health and Welfare. Chronic kidney disease – About. Canberra, ACT: AIHW, 2017. [Accessed October 2018].
2. Awdishu L, Mehta RL. The 6R’s of drug induced nephrotoxicity. BMC Nephrology 2017; 18:124.
3. Better Health Channel. Protein. Victoria: Department of Health & Human Services, 2018 [Accessed December 2018].
4. Britt H, Miller GC, Henderson J, et al. General practice activity in Australia 2014–15. General practice series no. 38. Sydney: Sydney University Press, 2015.
5. Centre for Disease Control. Healthy skin program: Guidelines for community control of scabies, skin sores, tinea and crusted scabies in the Northern Territory. Casuarina, NT: Department of Health, Northern Territory, 2015.
6. Jarred G, Kennedy LR. Therapeutic perspective: starting an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker in a diabetic patient. Ther Adv Endocrinol Metab. 2010, 1(1): 23–28.
7. Johnson D. Caring for Australasians with Renal Impairment (CARI) guidelines: Risk factors for early chronic kidney disease. South Melbourne, Vic: Kidney Health Australia, 2012. [Accessed October 2018].
8. Johnson DW. Evidence-based guide to slowing the progression of early renal insufficiency. Intern Med J. 2004; 34: 50–7.
9. Kidney Health Australia. Chronic Kidney Disease (CKD) Management in General Practice. Melbourne, Vic: Kidney Health Australia, 2015.
10. National Aboriginal Community Controlled Health Organisation and The Royal Australian College of General Practitioners.National Guide lifecycle chart (child). 3rd edn. East Melbourne, Vic: RACGP, 2018.
11. National Aboriginal Community Controlled Health Organisation and The Royal Australian College of General Practitioners.National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people: Evidence base. 3rd edn. East Melbourne, Vic: RACGP, 2018.
12. Toussaint N. Caring for Australasians with Renal Impairment (CARI) guidelines: Screening for early chronic kidney disease. South Melbourne, Vic Kidney Health Australia, 2012 [Accessed October 2018].