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Detailed guidance on the investigation and management of CKD can be found here. This link is useful to help determine the cause of albuminuria and/or renal impairment, which is critical for best management. The following guidance is a brief synopsis on the management of albuminuria and renal impairment relevant to CKM disease.
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Chronic kidney disease is defined as an eGFR <60mL/min and/or a urinary albumin:creatinine ratio (UACR) >3 mg/mmol for more than 3 months. Albuminuria, defined as a UACR > 3 mg/mmol, indicates endothelial inflammation. Renal impairment, defined as an eGFR < 60 mL/min, indicates renal damage or scarring. Both are independent risk factors for CV disease irrespective of each other or diabetes.
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Best management of CKD includes:
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Lifestyle management is always important with an aim for weight loss if overweight
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Start ACEi or ARB if blood pressure > 130/80 mmHg OR if any of the following are present if no concerns over hypotension:
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UACR > 3 mg/mmol and eGFR > 15 mL/min
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Diabetes mellitus (any type)
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Heart failure
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Provide advice on sick day management and titrate ACEi/ARB to maximal tolerated dose
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Check BP monthly until to target – if BP remains above target add calcium channel blocker (CCB) or thiazide diuretic (TD)
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If BP still above target then add other (e.g. TD if CCB previously added)
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ACEi, ARB, CCB and TD use and potential use of spironolactone is discussed in detail in management of elevated blood pressure
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Commence empagliflozin 10 mg daily if any of the following:
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UACR > 20 mg/mmol and eGFR > 20 mL/min
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Type 2 diabetes with UACR > 3 mg/mmol and/or eGFR 20 – 60 mL/min
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Heart failure if eGFR > 20 mL/min at any level of albuminuria
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eGFR 20 – 44 mL/min at any level of albuminuria
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NB: Only funded at present under special authority if heart failure and/or type 2 diabetes. Although expensive at $85 per month, self-funding should be offered. Tips to enhance access include:
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Utilising the disability allowance to cover the cost of empagliflozin if able
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Prescribing half the 25 mg tablet of empagliflozin or 1 tablet of empagliflozin 12.5 mg with metformin (Jardiamet) if type 2 diabetes to halve the cost to approximately $43 per month – please note this is off-label.
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Checking the cost between pharmacies because there continues to be wide variation
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Can increase to 25 mg daily if type 2 diabetes and HbA1c remains above target
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Glucose-lowering effects of empagliflozin reduce once eGFR < 30 mL/min
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Empagliflozin should only be stopped if adverse effects occur or dialysis is started.
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Sick day advice and tips to reduce adverse effects should be provided for all:
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Withhold empagliflozin in acute illness and 3 days before (including day of) major surgery, bowel prep or low carb diet. Restart when well and eating and drinking normal.
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Doses of sulfonylureas may need to be reduced by 50% and doses of inulin by approximately 20% to avoid hypoglycaemia when starting empagliflozin – typically only required when baseline HbA1c < 64 mmol/mol.
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Discuss importance of genital hygiene
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Do not use in pregnancy, breastfeeding or children < 10 years of age
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Do not use in type 1 diabetes, significant alcohol intake, previous diabetic ketoacidosis (DKA) or low carbohydrate diets without specialist advice
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If symptoms of DKA (e.g. nausea, vomiting, abdominal pain etc.) need to present to GP practice or A+E urgently to ensure blood ketones are < 1.5 mmol/L. DKA needs to be excluded if ketones > 1.5 mmol/L.
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Start lipid lowering therapy if high CV risk (5 year CV risk ≥ 10%) OR if any of the following are present irrespective of calculated CV risk aiming for LDL cholesterol < 1.4 mmol/L:
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Previous CV event and/or established CV disease
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Asymptomatic coronary or carotid disease
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Any type of diabetes with microvascular or macrovascular complication(s)
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UACR ≥ 30 mg/mmol
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eGFR < 45 mL/min
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UACR 3 – 29 mg/mmol and eGFR 45 – 59 mL/min
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Age > 50 years and UACR > 3 mg/mmol and/or eGFR < 60 mL/min
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Familial hypercholestraemia
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For others, lipid lowering therapy is strongly recommended if moderate CV risk (5 year CV risk 5-<10%) aiming for LDL cholesterol < 1.8 mmol/L, particularly if any significant risk factors:
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Direct family history of CVD at < 40 years of age
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Onset of cardiokidney metabolic disease < 40 years of age
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Severe mental illness particularly with antipsychotic use
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Cardiac calcium score ≥ 100
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Gout and/or autoimmune disease
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Previous gestational diabetes and/or preeclampsia
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Metabolic dysfunction-associated steatotic liver disase (MASLD; previously termed fatty liver disease)
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Lipid lowering therapy should be still considered if low CV risk (5 year CV risk < 5%) if any risk factors, particularly if 5 year CV risk ≥ 3% and/or LDLc > 4 mmol/L, but is largely driven by patient preference.
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Direct family history of CVD < 40 years of age
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Onset of CKM disease at < 40 years of age
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Severe mental illness particularly with antipsychotic use
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Cardiac calcium score ≥ 100
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Gout and/or autoimmune inflammatory disease
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MASLD
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Previous gestational diabetes and/or preeclampsia
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GLP1 receptor agonist (GLP1Ra) therapy should also be strongly considered if CKM present and type 2 diabetes with an HbA1c above if weight loss is desirable
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Please click here for more information on GLP1Ra use in diabetes
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Please click here for more information on GLP1Ra use for weight loss
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Aspirin is important for secondary prevention of CV events in renal disease. However, the risks of aspirin typically outweigh the benefits for primary prevention in people with significant renal disease
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The guidance in this section is largely based on the Kidney Disease / Improving Global Outcomes (KDIGO) 2024 Guidelines, which can be accessed at www.kdigo.org/guidelines/ckd-evaluation-and-management/