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CVD risk reduction PN

KCAT Primary Care Nurse WorkshopThis workshop was conceived and developed by the Kidney Check Australia Taskforce with particular thanks to Professor Vlado Perkovic and modified for general practice nurses by KCAT subcommittee V0914

Nurse leadership in cardiovascular risk reduction in Chronic Kidney Disease

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KCAT supportersThe KCAT program is proudly supported by unrestricted educational grants from:

KCAT Program Partners

KCAT Major Sponsor

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Learning outcomes

Understand the burden of Chronic Kidney Disease (CKD) in Australia and how to screen for it with a ‘Kidney Health Check’

Understand the importance of addressing cardiovascular risk in patients with chronic kidney disease (CKD)

Know the goals for management of CKD and Absolute Cardiovascular Risk and integrate the knowledge learned into your practice

Have increased knowledge of the difference a CKD diagnosis will make to the management strategies, treatment targets and therapy choices for patients

Improve patient safety outcomes by implementing nurse led systems to routinely assess and manage cardiovascular risk in patients with or at risk of CKD

At the end of this workshop participants will be able to:

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What is CKD?

Chronic kidney disease is defined as:

Glomerular Filtration Rate (GFR) < 60 mL/min/1.73m2 for ≥3 months with or without evidence of kidney damage.

OR

Evidence of kidney damage (with or without decreased GFR) for ≥3 months:• albuminuria• haematuria after exclusion of urological causes• pathological abnormalities• anatomical abnormalities.

Chronic Kidney Disease (CKD) Management in General Practice, 2nd edition. Kidney Health Australia: Melbourne, 2012

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CKD is a major public health problem

• 1 in 10 Australian adults has CKD

• Less than 10% of people with CKD are aware they have the condition

• You can lose up to 90% of your kidney function before experiencing any symptoms

• Major independent risk factor for cardiovascular disease

• Common, harmful & treatable

Australian Health Survey, 2013Chronic Kidney Disease (CKD) Management in General Practice, 2nd edition. Kidney Health Australia: Melbourne, 2012

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Australians aged ≥ 18 years

Australian Health Survey 2013; ABS population estimates June 2013; ANZDATA 2012 ReportCKD staging is according to the CKD-EPI equation

5+ MILLION AT RISK

1,146,000

21,000

54,000

591,000

Dialysis or transplant

Less than 10% of these people are aware they have CKD

Stage 4 - 5 CKD

Stage 3 CKD

Stage 1 - 2 CKD

Hypertension / Diabetes

Kidney disease in Australia

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

above risk factors

Eight major risk factors for CKD

DiabetesHigh blood pressure

SmokingObesity, BMI >30kg/m2

Age over 60 yearsAboriginal or Torres Strait Islander origin

Family history of kidney failureEstablished cardiovascular disease

RACGP Guidelines for preventive activities in general practice 8th edition; Chronic Kidney Disease (CKD) Management in General Practice, 2nd edition. Kidney Health Australia: Melbourne, 2012

Risk factors for kidney disease

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Screening for CKDRisk Factor Recommended Tests Frequency

Smoker

Urine ACReGFR

Blood Pressure

Every 1-2 years*

*annually for people with diabetes or

hypertension

Diabetes

Hypertension

Obesity

Established cardiovascular disease

Family history of kidney failure

Aboriginal or Torres Strait Islander origin aged over 30 years

Age over 60 This risk factor alone does not require regular testing

If an individual has multiple risk factors, follow a more frequent regime

RACGP Guidelines for preventive activities in general practice 8th edition; Chronic Kidney Disease (CKD) Management in General Practice, 2nd edition. Kidney Health Australia: Melbourne, 2012

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eGFR calculated from serum creatinine

Blood pressure *maintain

consistently below BP goals

Albumin / Creatinine Ratio (ACR)

to check for albuminuria

Kidney Health Check

Blood Test Urine Test BP Check

N.B. Dipstick testing is not a sufficient test for CKD screening

An eGFR < 60 mL/min/1.73m2 = increased risk of adverse renal, cardiovascular and other clinical outcomes, IRRESPECTIVE OF AGE

Kidney Health Check

Chronic Kidney Disease (CKD) Management in General Practice, 2nd edition. Kidney Health Australia: Melbourne, 2012

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• If the eGFR or ACR results are abnormal they will need to be repeated before CKD can be diagnosed

• The following algorithm, along with your ‘CKD management in general practice’ booklet, is a useful reference

What about abnormal results?

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Diagnose CKD and use table to define stage

Algorithm for detection of CKD

Chronic Kidney Disease (CKD) Management in General Practice, 2nd edition. Kidney Health Australia: Melbourne, 2012

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Staging CKD

Albuminuria Stage

GFR Stage

GFR (mL/min/1.73m2)

Normal(urine ACR mg/mmol)

Male: < 2.5Female: < 3.5

Microalbuminuria (urine ACR mg/mmol)

Male: 2.5-25Female: 3.5-35

Macroalbuminuria(urine ACR mg/mmol)

Male: > 25Female: > 35

1 ≥90 Not CKD unless haematuria, structural

or pathological abnormalities present2 60-89

3a 45-59

3b 30-44

4 15-29

5 <15 or on dialysis

Colour-coded Clinical Action Plans

X

Combine eGFR stage, albuminuria stage and underlying diagnosis to specify CKD stage

(e.g. stage 3b CKD with microalbuminuria secondary to diabetic kidney disease)

Chronic Kidney Disease (CKD) Management in General Practice, 2nd edition. Kidney Health Australia: Melbourne, 2012

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• CKD is one of the most potent known risk factors for cardiovascular disease

• It is essential to clinically determine the risk of CKD before using the Australian absolute cardiovascular risk tool (www.cvdcheck.org.au ) to accurately calculate cardiovascular risk

• Individuals with CKD have a 2-3 fold greater risk of cardiac death than individuals without CKD

• People with CKD are at least 20 times more likely to die from cardiovascular disease than survive to need dialysis or transplant

Cardiovascular risk reduction in CKD

Chronic Kidney Disease (CKD) Management in General Practice, 2nd edition. Kidney Health Australia: Melbourne, 2012

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Case study - Tony

Background• 54 years old• Works in family retail business• Enjoys watching sport

TodayTony sees you for his usual blood pressure lowering prescription.

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Medical history

• High blood pressure, diagnosed 18 years ago

• Dyslipidaemia, diagnosed 6 months ago• Currently on trial of dietary management

• Chronic kidney disease:• Stage 3b CKD with microalbuminuria• 6 months ago: eGFR 38 mL/min/1.73m2

• urine ACR 21mg/mmol

• Knee osteoarthritis

Case study - Tony

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Case study - Tony

Previous smoker:

Ceased smoking 8 years ago after 25 pack-year history

Alcohol: 3-4 glasses of wine each week

Allergies: Nil known

Medications: Nifedipine SR 60 mg daily with no side effects

Tony hasn’t always been interested in preventative care.

However... His cousin has just had a primary coronary angioplasty for a MI aged 55 years, and he is worried this could happen to him.

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On examination• BP 150/90 mmHg (145/95mmHg 3 months ago)• Weight 86 kg, height 1.75m, BMI 28

Case study - Tony

InvestigationsFasting bloods

BSL 5.6 mmol/L

K+ 4.2 mmol/L

Creatinine 165 µmol/L

eGFR 40 mL/min/1.73m2

Total cholesterol 6.7 mmol/L

HDL cholesterol 1.4 mmol/L

LDL cholesterol 3.2 mmol/L

Triglycerides 2.4 mmol/L

Urine ACR (early morning) 22.6 mg/mmol

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Case study – QuestionQ1: How do you establish Tony’s risk of experiencing

a CVD event in the near future?

a) Use individual risk factors to make the assessment and treat each risk factor on its own merit

b) Assess absolute cardiovascular risk using Australian risk calculator

c) As Tony has stage 3b CKD he is clinically determined to be at high risk of experiencing a CVD event in the next 5 years

d) Focus on hypertension as the most important risk factor and manage that appropriately

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Absolute cardiovascular risk• Is a measure of the risk of subsequent cardiovascular

events for a person based on a range of established risk factors

Blood pressure, cholesterol, age, diabetes, smoking history

• A range of calculators are available, but most are based on variants of the Framingham risk equation

• Recent unified guidelines were published by National Vascular Disease Prevention Alliance (NVDPA) in Australia, after approval by the NHMRC

• Australian risk calculator recommended: www.cvdcheck.org.au

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CVD riskAustralian Absolute Cardiovascular Disease Risk Calculator

www.cvdcheck.org.au

Tony has an eGFR of 40 mL/min/1.73m2

He is at high risk (>15% chance) of a CVD event in next 5 yrs. He should not have the Absolute CVD risk tool applied.

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anyone with…• eGFR < 45 mL/min/1.73m2 or persistent proteinuria• Diabetes and microalbuminuria • Diabetes and age > 60 years• Established cardiovascular disease• Familial hypercholesterolaemia or total cholesterol above

7.5• Severe hypertension

– Systolic 180 mmHg or greater– Diastolic 110 mmHg or greater

is already at the highest risk of a cardiovascular event Therefore the calculator should not be used

CVD risk

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CVD riskeGFR <60mL/min defines a coronary heart disease risk greater than diabetes

Tonelli, Lancet 2012CKD defined as eGFR 15-59.5ml/min per 1.73m2

CKD Diabetes

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• Lower eGFR is a strong predictor of increased CVD risk

• Higher urine albumin excretion also predicts increased risk

• The two provide independent information so that individuals with both risk factors have the highest risk

• These markers are additional to the information provided by traditional risk factors

CVD risk - summary

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Case study - answer

a) Use individual risk factors to make the assessment and treat each risk factor on its own merit

b) Assess absolute cardiovascular risk using Australian risk calculator

c) As Tony has stage 3b CKD he is clinically determined to be at high risk of experiencing a CVD event in the next 5 years

d) Focus on hypertension as the most important risk factor and manage that appropriately

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Target blood pressure in adults

Blood pressure goals

Patient Group People with....

Maintain BP consistently BELOW (mmHg)

Albuminuria <130/80

Diabetes <130/80

Chronic Kidney Disease <140/90

KHA-Cari guidelines-Primary prevention of chronic kidney disease:Blood pressure target

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Case study – QuestionQ2: What could you (his nurse) do to assist in

reducing Tony’s risk of cardiovascular disease?

272727Tiberio MFrisoli et al Beyond salt; lifestyle modifications and blood pressure: European Heart Journal (2011) 32, 3081–3087 doi:10.1093/eurheartj/ehr379

Modification Recommendation

Weight reduction BMI 18-24.9 kg/m2 4.4mmHg (for 5.1kg weight lost)

Dietary sodium restriction

Reduce dietary sodium intake to no more than 2.4g sodium(or 6g salt)

4-7 mmHg(for reduction by 6g in daily salt intake)

DASH diet Fruit, vegies, low saturated and total fat

5.5-11.4 (5.5 for normotensives 11.4 for hypertensives)

Physical activity Aerobic activity for 30-60mins/day, 3-5 days/week 5mmHg

Moderate alcohol consumption only

No more than 2 drinks per day (men) or 1 drink per day(women)

3mmHg(For 67% reduction from baseline of 3-6 drinks per day

Lifestyle effects on BP

282828

150/90

Bakris et al., Am J Kid Disease, 2000

If Tony’s BP was consistently below target, his GFR loss per year would be reduced by 62%

Adequate BP management delays the progression of CKD (reduces the GFR drop/year)

Hypertension

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Blood pressure and medications• CKD can cause /aggravate hypertension and hypertension can

contribute to the progression of CKD

• Maintaining blood pressure below target levels is one of the most important goals of CKD management

• ACE inhibitor or ARB is recommended first line therapy

• Combined therapy of ACE & ARB is not recommended

• Maximal tolerated doses of ACE inhibitor or ARB is recommended.

• Hypertension may be difficult to control and multiple (3-4) medications are frequently required

• Consider organising a Home Medicines review (HMR)

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Case study – Tony

Q3: Discuss the role of the practice nurse in monitoring Tony’s CKD, and cardiovascular disease risk

• The GP has prescribed Tony an ACE inhibitor and an appointment is made for you, the practice nurse, to see him

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Chronic disease managementMedicare Australia has provided remuneration for chronic disease management by the following item numbers:

For more information visit www.mbsonline.gov.au

GP Management Plan

Items 721, 729 & 732

For patient and GP management of chronic disease

Incorporates patients goals, needs, achievements and references to resources

Electronic templates for specific conditions are available

CKD template available at kcat@kidney.org.au

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Case study - TonyYou discuss Tony’s management plan with him.

Tony…

• Suggests that his main issues are lack of exercise, nutrition (hyperlipidaemia) and hypertension.

• Agrees that learning self management principles may assist him

• plans to utilise his five services under GPMP/TCA by seeing a dietitian and exercise physiologist

Dietary changes and exercise plans that form part of Tony’s management are hoped to impact on his hyperlipidaemia and hypertension, and reduce his BMI from 28 by your follow up visit in 6 months time.

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Case study – Question

Q4: After 6 months of dietary therapy Tony’s lipid results are not at target. Would he benefit from statin therapy?

Tony returns for a follow-up appointment 6 months later

YESThere is strong evidence that lipid lowering in people with CKD will decrease the risk of atherosclerotic events

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SHARP results: 17% reduction in major atherosclerotic events*

Years of follow-up 0 1 2 3 4 5

0

5

10

15

20

25

Prop

ortio

n su

fferin

g ev

ent*

(%)

Risk ratio 0.83 (0.74 – 0.94)Log rank p=0.0022

Placebo

Eze/simv

Baigent et al, Lancet 2011

*Major atherosclerotic events (coronary death, MI, non-haemorrhagic stroke, or any revascularization)

*Average 0.85mmol/L decrease in LDL-C vs. placebo

17% reduction in risk

CV events

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Case study - Tony

Investigations Tony ACVR GuidelinesFasting bloods

Total cholesterol 7.0 mmol/L <4 mmol/L

HDL cholesterol 1.0 mmol/L 1 mmol/L

LDL cholesterol 3.4 mmol/L <2 mmol/L

Triglycerides 2.6 mmol/L <2 mmol/L

• Both you and the dietitian reinforce Tony’s dietary efforts

• You support Tony with commencement of medication for cholesterol lowering after reassuring him that the use of Lipids is ok in CKD

After 6 months of dietary therapy:

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Case study – QuestionQ5: Is antiplatelet therapy routinely recommended as

CVD primary prevention in people with CKD?

Tony mentions his cousin is now taking aspirin daily and asks if he should too.

a) Yesb) Noc) Possibly – it is important to balance risks

against benefits

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Summary of CVD risk reduction in CKD• BP lowering and lipid lowering have evidence to support their

efficacy at reducing CVD risk in people with CKD

• BP lowering may also protect against progressive kidney disease, especially in people with albuminuria

• Aspirin shown to reduce CVD risk in hypertensive people with CKD in a single study*

Confirmation in other studies required

• Aspirin likely increases bleeding risk, and this needs to be balanced against the benefits at an individual level

• Dual RAS blockade may be harmful and should not be routinely used

Jardine et al, JACC 2010

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YES• The CV risk categorisation using the Absolute Risk

Tool is misleading unless CKD status is known

• The targets of therapy (BP, anti-platelets) are different if CKD is present

• The benefits of achieving targets in people with CKD are in general greater and include reduction in risk of progression to kidney failure

Case study – QuestionQ6: Does knowing Tony’s CKD status impact on CVD

risk reduction management?

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As Tony has Stage 3b CKD with Microalbuminuria follow the Orange clinical action plan outlined in the CKD Management

in general practice booklet.

• 3-6 monthly clinical review

• Continue with pharmacological and lifestyle interventions to reduce absolute cardiovascular risk

Case study – Tony

What’s next for Tony?

Orange Clinical Action PlaneGFR 30-59 mL/min/1.73m2 with microalbuminuria or

eGFR 30-44 with normoalbuminuria

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Screening and assessments

Screen those at risk

Diabetes

Family history of kidney failure

Established CVD

High blood pressure

Obese (BMI >30kg/m2

Smoker

Aboriginal or Torres Strait Islander origin

Screening - search* for patients at risk and invite patients for a health checkHealth Assessments (Items 701, 703, 705, 707, 715)

*Use data management tools such as ‘PEN CAT’ to help find patients at risk

For more information visit www.mbsonline.gov.au

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CKD screening and management

Kidney Health Check and CKD management should become an integral part of Chronic Disease Management and screening processes in your practice

• Screening and assessments

• Annual diabetes cycle of care

• Chronic disease management

• Team care

• Management reviews

Kidney Health Check = Blood, Urine, BP

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Lifestyle and referral pathways

• Give patient SNAP guidelines and relevant education brochures on CKD (see www.kidney.org.au)

• Referral to exercise physiologist, dietitian• Referral to local lifestyle intervention

programs (Check with Medicare Local)

• Encourage patient to practice self management strategies and provide self management support

• Home medicines review

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Conclusion

• You need to know the CKD status before assessing Cardiovascular risk

• Moderate to severe CKD is a clinical determinant of high Cardiovascular risk

• Ignorance of CKD status when assessing CVD risk using the Absolute Risk Tool (or by any other means) may seriously underestimate the CVD risk in an individual and lead to incorrect management

• The benefit of CVD risk reduction in people with CKD is proven and is increased with greater severity of CKD

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Key messages

• Established cardiovascular disease is one of the eight major risk factors for CKD

• The role of the Practice Nurse is important in the early detection and treatment of CKD

• Early detection may reduce the rate of progression of kidney failure & cardiovascular risk by 20-50%

• Nurses can implement change and play a key role

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Available at

ResourcesCKD management in general practice2012 Guidelines booklet

www.kcat.org.au

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Available at

ResourcesGuidelines for the assessment and management of Absolute Cardiovascular Disease RiskNational Vascular Disease Prevention Alliance

www.cvdcheck.org.au

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Available at www.kidney.org.au

ResourcesCKD management guidelines for general practice

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Available along with more kidney health fact sheets atwww.kidney.org.au > For Patients > Health Fact Sheets

ResourcesCKD Patient fact sheets

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Free call information service for people living with / affected by kidney disease

ResourcesKidney Health Information Service

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Join the Kidney CommunityKIDNEY COMMUNITY members receive a monthly newsletter from KHA allowing you to access:• Information and invitations to KHA's education and support

activities• Updates on medical research in kidney disease• Updates on clinical trials and research opportunities• Information on advocacy opportunities and government

relations issues• Information on community and corporate events held

by Kidney Health Australia

To join the kidney community, email community@kidney.org.au

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