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Clinical guidelines

Guidelines for preventive activities in general practice 9th edition

8.6 Kidney disease

Age 0-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-79 > 80

Approximately 1.7 million Australians aged >18 years have reduced kidney function and/or albumin in the urine,75 but only 10% are aware of this.76 CKD may be a stronger risk factor for future coronary events and all-cause mortality than diabetes.77 Early management of CKD includes CVD risk factor reduction, lifestyle changes and prescription of angiotensin-converting-enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs).78 Patients should be screened for kidney disease if they are at high risk (B).

Table 8.6.1. Kidney disease: Identifying risk
Who is at risk?What should be done?How often?
High risk
  • Smoking
  • Obesity (body mass index [BMI] >30 kg/m2)
  • Family history of kidney failure
  • Diabetes
  • Hypertension
  • Aboriginal or Torres Strait Islander peoples aged >30 years
  • Established cardiovascular disease (CVD), coronary heart disease (CHD) or peripheral vascular disease (PVD)
  • History of acute kidney injury
Blood pressure (BP), albumin-to-creatinine ratio (ACR) and estimated glomerular filtration rate (eGFR; III, A) 79–88, 92–94

If ACR is positive, arrange two further samples for urine ACR over two months (III, B)57, 88–91

If eGFR <60 mL/min/1.73 m2, repeat within seven days
Every one to two years * (IV, C)
* One year for patients with hypertension or diabetes

ACR, albumin-to-creatinine ratio; BMI, body mass index; BP, blood pressure; CHD, coronary heart disease; CVD, cardiovascular disease; eGFR, estimated glomerular filtration rate; PVD, peripheral vascular disease
Table 8.6.2. Tests to detect kidney disease
TestTechnique
Albuminuria Estimation of urine albumin-to-creatinine ratio (UACR), preferably on a first morning void. Note: Dipstick urine test is not adequate to identify microalbuminuria 88, 90

Albumin-to-creatinine ratio (ACR)
FemalesMales
Normal <3.5 mg/mmol <2.5 mg/mmol
Microalbuminuria 3.5–35 mg/mmol 2.5–25 mg/mmol
Macroalbuminuria >35 mg/mmol >25 mg/mmol
Estimated glomerular filtration rate (eGFR) This is currently automatically reported with every test for serum creatinine using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula (staging is based on both eGFR level and UACR [normoalbuminuria, microalbuminuria or macroalbuminuria]):78, 89, 95
  • Stage 1: >90 mL/min/1.73 m2 with microalbuminuria, proteinuria or haematuria with the presence of structural or pathological abnormalities
  • Stage 2: 60–89 mL/min/1.73 m2 with microalbuminuria, proteinuria or haematuria with the presence of structural or pathological abnormalities
  • Stage 3a: 45–59 mL/min/1.73 m2
  • Stage 3b: 30–44 mL/min/1.73 m2
  • Stage 4: 15–29 mL/min/1.73 m2
  • Stage 5: (end-stage): <15 mL/min/1.73 m2
Refer patients with Stage 4 or 5 to a renal unit or nephrologist, and consider referral at Stage 3 or earlier if:
  • persistent significant albuminuria (UACR ≥30 mg/mmol)
  • a sustained decrease in eGFR of 25% or more OR a sustained decrease in eGFR of 15 mL/min/1.73 m2 within 12 months
  • chronic kidney disease (CKD) with hypertension that is hard to get to target despite at least three antihypertensive agents
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Note: eGFR and the presence and severity of albuminuria reflects the risk of cardiovascular disease (CVD) progression and future cardiovascular events

The eGFR may be unreliable in the following situations:
  • acute changes in renal function
  • patients on dialysis
  • certain diets (eg vegetarian, high protein, recent ingestion of cooked meat)
  • extremes of body size
  • muscle diseases (may overestimate) or high muscle mass (may underestimate)
  • children <18 years of age
  • severe liver disease
ACR, albumin-to-creatinine ratio; CKD, chronic kidney disease; CKD-EPI, Chronic Kidney Disease Epidemiology Collaboration; CVD, cardiovascular disease; eGFR, estimated glomerular filtration rate; UACR, urine albumin-to-creatinine ratio

References

  1. Iseki K, Ikemiya Y, Iseki C, Takishita S. Proteinuria and the risk of developing end-stage renal disease. Kidney Int 2003;63:1468–74.
  2. Australian Bureau of Statistics. Australian health survey: Biomedical results for chronic diseases, 2011–12. Canberra: ABS, 2013.
  3. Australian Bureau of Statistics. Australian health survey: First results 2011–12. Canberra: ABS, 2012.
  4. Tonelli M, Muntner P, Lloyd A, et al. Risk of coronary events in people with chronic kidney disease compared with those with diabetes: A population-level cohort study. Lancet 2012;380(9844):807–14.
  5. Kidney Health Australia. Chronic kidney disease (CKD) management in general practice. 3rd edn. South Melbourne, Vic: Kidney Health Australia, 2015.
  6. Wang Y, Chen X, Song Y, Caballero B, Cheskin LJ. Association between obesity and kidney disease: A systematic review and meta-analysis. Kidney Int 2008;73(1):19–33
  7. Johnson D. Evidence-based guide to slowing the progression of early renal insufficiency. Intern Med J 2004;34:50–57.
  8. Hallan SI, Dahl K, Oien CM, et al. Screening strategies for chronic kidney disease in the general population: Follow-up of cross sectional health survey. BMJ 2006;333(7577):1047.
  9. Fox C, Larson MG, Leip EP, Culleton B, Wilson PWF. Predictors of new-onset kidney disease in a community-based population. JAMA 2004;291:844–50.
  10. Crowe E, Halpin D, Stevens P. Early identification and management of chronic kidney disease: Summary of NICE guidance. BMJ 2008;337:a1530.
  11. Chadban S, Briganti EM, Kerr PG, et al. Prevalence of kidney damage in Australian adults: The AusDiab kidney study. J Am Soc Nephrol 2003;14(7 Suppl 2):S131–38.
  12. Astor BC, Hallan SI, Miller ER, Yeung E, Coresh J. Glomerular filtration rate, albuminuria, and risk of cardiovascular and all-cause mortality in the US population. Am J Epidemiol 2008;167(10):1226–34.
  13. Angelantonio ED, Chowdhury R, Sarwar N, Aspelund T, Danesh J, Gudnason V. Chronic kidney disease and risk of major cardiovascular disease and non-vascular mortality: Prospective population based cohort study. BMJ 2010;341:4986.
  14. Hoy W, Mathews J, McCredie D, Pugsley D, Hayhurst B. The multidimensional nature of renal disease: Rates and associations of albuminuria in an Australian Aboriginal community. Kidney Int 1998;54:1296–304.
  15. Methven S, MacGregor MS, Traynor JP, Hair M, St J O’Reilly D, Deighan CJ. Comparison of urinary albumin and urinary total protein as predictors of patient outcomes in CKD. Am J Kidney Dis 2010;57(1):21–28.
  16. Levey AS, Coresh J, Balk E, Kausz AT, Levin A. National Kidney Foundation practice guidelines for chronic kidney disease: Evaluation, classification, and stratification. Ann Intern Med 2003;139(2):137–47.
  17. Eknoyan G, Hostetter T, Bakris GL, et al. Proteinuria and other markers of chronic kidney disease: A position statement of the National Kidney Foundation (NKF) and the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Am J Kidney Dis 2003;42:617–22.
  18. Bleyer A, Shemanski LR, Burke GL, Hansen KJ. Tobacco, hypertension, and vascular disease: Risk factors for renal functional decline in an older population. Kidney Int 2000;57:2072–79.
  19. Scottish Intercollegiate Guidelines Network. Diagnosis and management of chronic kidney disease: A national clinical guideline. Edinburgh: SIGN, 2008.
  20. 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. 2nd edn. East Melbourne, Vic: RACGP, 2012.
  21. Kidney Health Australia. National Chronic Kidney Disease Strategy. Melbourne: KHA, 2006.
  22. Levey AS, Stevens LA, Schmid CH, et al. A new equation to estimate glomerular filtration rate. Ann Intern Med 2009;150(9):604–12.
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