Wendy Washington & Anne Graham Nephrology Nurse Practitioners

Eight major risk factors for CKD Diabetes

High blood pressure Age over 60 years

Smoking Obesity

Family history of kidney disease Aboriginal or Torres Strait Islander origin

Established cardiovascular disease

1 in 3 Australian adults is at increased risk of CKD due to the above risk factors!

The new Australian CKD staging schema Albuminuria Stage

GFR Stage GFR (mL/min/1.73m2)

Normal (urine ACR mg/mmol) Male: < 2.5

Female: < 3.5

Microalbuminuria (urine ACR) Male: 2.5-25

Female: 3.5-35

Macroalbuminuria (urine ACR mg/mmol)

Male: > 25 Female: > 35

1 ≥90 Not CKD unless haematuria, structural

or pathological abnormalities present 2 60-89

3a 45-59

3b 30-44

4 15-29

5 <15 or on dialysis <GFR + albuminuria =

> risk of CKD & CVD

more than just one

5 MILLION AT RISK

856,000

18,000

40,000

827,000

Stage 5 not on dx

Stage 4 CKD

Stage 3a and b CKD

Hypertension or Diabetes

Stage 1 – 2 CKD

Kidney Disease in Australia

Australians aged ≥ 25 years

CKD staging is according to the CKD-EPI equation

AusDiab Report, 2001; White et al 2010; Jun 10 ABS data; 2010 ANZDATA report

Comparing GFR and Creatinine . CKD 1&2

CKD 5

CKD 4

CKD 3

GFR mL/min Dialysis

120 90 60 30 0

Seru

m c

reat

inin

e

Albuminuria

Normal blood level

Diabetic Kidney Disease (DKD) and end-stage renal disease (ESRD ) in Australia1

DKD is now the most common cause of patients commencing dialysis in Australia (and QLD)1

DKD accounts for 35% of new ESRD patients with 90% of these Type 2 (15% non insulin) (ANZDATA - Australia and NZ)1

Five year survival for diabetics entering dialysis is only 5% compared to 20% for non-diabetics

T1DM ESRD patients have 1.77 relative risk of mortality. T2DM ESRD patients have a 1.27 relative risk of mortality

compared to non-DM patients 1. ANZDATA 2011

Chronic Kidney Disease (CKD) CKD team (North Ward) work to slow

progression, to delay or prevent dialysis. NP, dietitian, social worker 693 patients, 132 JPHS, 559 TTH Diabetes on care plan 226 (?%) 340 (61%) Proteinuria on care plan 9 78 (FERRET database)

1st March’13 albuminuria

TSV 78

JPHS 9

GFR Non DM DKD Non DM DKD >90 26 29 60-89 60 51 30-59 303 36 15-29 135 13 <15 35 3 Total 559 340 132 226

Principal goals of CKD management

Self Management of chronic conditions to slow progression Reduction of cardiovascular and kidney risk factors Early detection and management of CKD complications Avoid nephrotoxic medications Ensure all medication doses are appropriate for stage of CKD Manage contributing cause Timely referral to a Nephrologist (GFR<30 or <60 if DKD) Discuss by Stage 4 re dialysis, transplant, conservative care If planning haemodialysis, AVF creation at eGFR 15 Home dialysis has best outcomes

Diabetes mellitus and ESKD1 Poor pre-dialysis glycaemic control as a predictor of mortality

in type 2 diabetic patients on haemodialysis

1. Adapted from Wu, M. NDT 1997 :12

KHA – Diabetic Kidney Disease Major Cause of Kidney Failure - March 2010

Research shows 27% of people commencing dialysis did not see a

Nephrologist until < three months prior to their kidneys failing.

KHA shows only 8.4% of the general population in surveys identifies Diabetes as a cause of kidney disease.

People can lose 90% of their kidney function with no symptoms.

Combined this with a major community information gap over the link

between Type 2 Diabetes and kidney failure.

Screening is simple- Quarterly Blood pressure check

Annual blood and urine (albuminuria, ACR and creatinine)

Diabetic patients on dialysis ANZDATA as at 31/12/09 (209 pts)

Townsville Australia

T2DM on Insulin 29 (14.6%) 1940 (16.8%)

T2DM Non Ins 83 (41.4%) 2440 (21.1%)

T1DM I 6 (3.3%) 398 (3.4%)

No Diabetes 81 (40.7%) 6802 (58.7%)

Renal Replacement Therapy

18,999 (474 per million) people received renal replacement therapy at 31st December 2010.

Of these, 8,409 (474 per million) had a functioning kidney transplant and

10,590 (459 per million) receiving dialysis and 1208 (2151 per million) were Aboriginal or Torres Strait Islanders

A clear vision of Starting dialysis

Townsville Patient Treatment Options

Transplant – PAH only after extensive workup Hospital Haemodialysis at TTH Satellite Haemodialysis at:

Home Hill Mt Isa Palm Island North Ward Community Campus

Home: Haemodialysis, CAPD, APD Visiting every 3/4 months; contact monthly

Transplantation Transplant is a treatment, not a cure. Organ

failure and rejection can happen at any time. Medication Forever

Only Qld transplant unit is PAH, Brisbane With Diabetes, aim for combined Pancreas

and Kidney – only Sydney or Melbourne Problems are damage to other organs and

vessels from diabetes may prevent this option

Goals of Dialysis

Remove waste products (urea, creatinine) Remove some toxins Balance electrolytes Replenish bicarbonate (acid base balance) Remove excess water

Haemodialysis regimens Intermittent haemodialysis (3x/wk): Incenter,

Satellite, home. (usually 5 hours) Daily dialysis – done at home. Nocturnal slow dialysis is the best (at home). Haemofiltration, replacement of all the

electrolyte fluid with new

Haemodialysis Semipermeable

membrane. Cellulose or

biocompatible synthetic

Hollow fibre Blood in the hollow

tubes and electrolyte fluid surrounding it

Cannulation of Arterio-Venous Fistula for Dialysis

What is actually seen Computer/ alarm system

Both blood and fluid alarm systems

Blood Pump (300ml/min)

Dialyser

Bicarbonate and Electrolyte concentrate

Heparin

Air Detectors

PERITONEAL DIALYSIS Continuous Ambulatory Peritoneal dialysis (C.A.P.D)

Automated Peritoneal Dialysis (A.P.D) where machine does it overnight so you have days free

DIANEAL Dianeal uses Glucose to produce an osmotic

gradient which moves extracellular fluid into the peritoneal cavity, to remove excess fluid no longer excreted by Kidneys.

The higher the strength of glucose, the greater the fluid loss 0.55%; 1.5%; 2.5%; 4.25%

The least Glucose load = 3 bags 1.5% dextrose And 1.5% glucose is 83mmol of Glucose = Increased insulin requirement (may be overnight)

HEMODIALYSIS V’S PERITONEAL DIALYSIS (all free on Medicare) HEMODIALYSIS Need access to good

blood supply Needles access blood Good water and

electricity supply essential

Need a dialysis partner Need a machine

P. D Need access to the

peritoneum Must have clean area Need to learn sterile

“no touch” technique Dialysis is performed

all day everyday

Townsville - Renal Service About 500,000 sq. km.

Bigger than Victoria, not quite as big as NSW

Mostly coastal towns but inland communities

eg.Mt Isa several indigenous

communities High CKD and dialysis in

remote areas Up to 1 in 70 dialysis

dependent in some areas.

Townsville reality Townsville has approx 230 Dialysis Clients

attached to its service > 50% have Diabetic Kidney Disease 78 are on home dialysis, so back in their own

homes and communities (spending between 2 weeks to 2 years stuck in Townsville)

Current QH policy aims for minimum 40% clients on Home dialysis with a 50% target.

Those Not at Home We have 3 rural or remote Satellite dialysis

units but all clients start in Townsville and all return here if problems

16 in Mt Isa Unit 3 in Joyce Palmer Palm Island Unit 12 in Home Hill Unit The other 125 dialyse at TTH or North Ward.

The 125 in Townsville 53% are ATSI 34% come from rural and remote areas

That number has been about 1/3 for several years Mt Isa and surrounds, 31 clients so ¾ of those

inc Mornington Island, Doomadgee, Burketown….. Flinders Highway -Charters Towers to Richmond Palm Island, Magnetic Island Bruce Highway Cardwell to Burdekin or Bowen.

Added impact of CKD Having CKD does not mean other things go

away. Still worry about feet, eyes, heart ….. Pill burden is higher than non CKD as

addition of medications for CKD if it worsens; may change after every blood test.

Changing insulin or oral agents required

Psychosocial Impact Coping with chronic illness –anxiety,

depression Haemodialysis is at least 5 hours every

second day. Isolated in TSV when you need most support Usually unable to attend important events;

births, birthdays, weddings, sorry business. Distance home, expensive and few flights

Take home message CKD prevention or slowing progression is possible

from preventable causes. BGL and BP control Referral to CKD team and Nephrologists earlier Combined Pancreas- Kidney transplant if suitable. If dialysis inevitable - home dialysis best outcomes

(long slow nocturnal Hd = same as transplant) PD first maintains residual renal function longer,

then home nocturnal Haemodialysis

New Edition! now

available at www.kcat.org.au

Further Resources…

CKD Management in General Practice

2012 Guidelines booklet