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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
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)
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


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