General practice and primary health care
One of the main goals of primary health care for chronic kidney disease (CKD) is the preservation of kidney health. Collaboration between general practitioners (GPs), nurse practitioners, primary health care nurses and people with CKD is recognised as an important part of the ongoing treatment and management of CKD, and primary health care providers have a role in supporting individuals’ self-management of this condition (Bear and Stockie 2014; Havas et al. 2017; KHA 2020a).
Diagnosis and detection of chronic kidney disease in general practice
The asymptomatic nature of CKD in stages 1–4 make GP and primary health care settings particularly important in detecting and reducing the burden of CKD.
CKD is chronically underdiagnosed in the Australian population, with only 6.1% of adults who showed biomedical markers of CKD in 2011–12 also self-reporting having the disease (ABS 2013). According to recent evidence, 88% of people with stages 1–2 CKD and 80% of people with stage 3 CKD may be undiagnosed (Khanam et al. 2019, NPS MedicineWise 2020).
Because CKD requires signs of reduced kidney function or damage to be present for at least 3 months, diagnosis involves biomedical assessments (blood and/or urine tests) to be repeated more than 3 months apart. This can make the disease more difficult to detect and diagnose.
Given the rates of under-diagnosis and the high burden of CKD, targeted screening of individuals at increased risk of developing CKD due to the presence of one or more risk factors and performing kidney health checks of those people is the clinical protocol recommended in Australia for detecting CKD (KHA 2020a).
Chronic kidney disease management in general practice
Kidney Health Australia guidelines for the clinical management of CKD in primary health care involve regular monitoring of patients with CKD (KHA 2020a). Although these guidelines are endorsed by The Royal Australian College of General Practitioners, the Australian Primary Health Care Nurses Association and the Australian and New Zealand Society of Nephrologists, complete monitoring of people with CKD in Australia is inadequate (Khanam et al. 2019, NPS MedicineWise 2020).
Clinical monitoring of chronic kidney disease
Monitoring of CKD depends on the level of kidney function, with worse function requiring more assessments.
Standard monitoring of CKD requires the following tests:
Urinary albumin:creatine ratio (urine ACR) is a urine test to detect the presence of albumin (protein) in the urine, which would normally be filtered out by the kidneys. If kidney function is reduced, protein may pass from the blood into the urine, causing albuminuria. Albuminuria is indicative of CKD, even if other tests are normal (KHA 2017a).
Estimated glomerular filtration rate (eGFR) is a blood test that provides an indication of how well the kidneys are filtering waste from the blood. It is used to diagnose the stage of CKD and to monitor progression of the disease (KHA 2020b).
Electrolytes is a blood test that measures sodium and potassium levels in the blood, which should be properly balanced to maintain the normal function of metabolic processes.
Glycated haemoglobin (HbA1c) is the main biomarker used to assess long-term glucose control in people living with diabetes. It forms part of monitoring CKD only in people with diabetes.
Fasting lipids are used to determine cardiovascular disease risk and monitor disease progression. Dyslipidaemia, or an altered lipid profile in the blood, can accelerate the rate of kidney function decline.
Blood pressure tests are needed to identify high blood pressure, which can both cause and exacerbate CKD. Controlling high blood pressure is an important component in the treatment and management of CKD.
Additional assessments that may be required depending on kidney function include:
Full blood count can detect anaemia (deficiency in the number or quality of red blood cells) and monitor iron levels. Anaemia is a common complication of CKD, and can cause damage to other organs as well as reducing quality of life in severe cases.
Calcium and phosphate need to be maintained at healthy levels to help protect against heart disease and stroke, and to prevent bones from weakening. In more advanced stages of CKD, the kidneys do not activate Vitamin D, which is necessary for the body to absorb calcium and phosphate. Calcium and phosphate levels may need to be controlled through diet and the use of phosphate binders and Vitamin D supplements (KHA 2017b).
Parathyroid hormone (PTH) can detect hyperparathyroidism, which disrupts calcium levels and can lead to kidney failure.
According to a recent study of people with CKD in general practice, in 2018–19:
- 45% of those in Australian primary health care received complete monitoring (as defined by a record of urine ACR, eGFR, cholesterol (lipids), HbA1c (if diabetic), haemoglobin (full blood count), and blood pressure measurement).
- among those with diabetes, 68% received complete monitoring, compared with 28% of those without diabetes.
- those with stages 1–2 CKD were almost twice as likely to receive complete monitoring compared with those with stages 3–5 (81% compared with 41%), possibly due to a higher proportion of people with stages 1–2 CKD having diabetes (NPS MedicineWise 2020).
Factors associated with reduced monitoring of CKD were older age and living in a disadvantaged socioeconomic area, compared with co-existing diabetes or hypertension, and having a documented CKD diagnosis, which were positively associated with complete monitoring (Khanam et al. 2019).
National key performance indicators
Data on chronic disease management in Indigenous-specific primary health care are provided by organisations funded under the Australian Government’s Indigenous Australians’ Health Programme (AIHW 2022).
Based on data from the national Key Performance Indicator collection, as at June 2021:
- 63% of Indigenous regular clients aged 15 and over with type 2 diabetes had an eGFR and/or urine ACR or other micro albumin test recorded within the previous 12 months.
- 62% of Indigenous regular clients aged 15 and over with cardiovascular disease had an eGFR and/or urine ACR or other micro albumin test recorded within the previous 12 months.
Of those who had an eGFR test recorded:
- 80% of Indigenous regular clients with type 2 diabetes had an eGFR in the ideal range (≥60mL/min/1.73m2), within the previous 12 months.
- 77% of Indigenous regular clients with cardiovascular disease had an eGFR in the ideal range (≥60mL/min/1.73m2), within the previous 12 months.
- Of those who had a urine ACR test recorded:
- 43% of Indigenous regular clients with type 2 diabetes had an ACR of <2.5 (males) or <3.5 (females), within the previous 12 months.
ABS (Australian Bureau of Statistics) (2013) Australian Health Survey: biomedical results for chronic diseases, ABS, Australian Government, accessed 22 February 2022.
AIHW (Australian Institute of Health and Welfare) (2022) Aboriginal and Torres Strait Islander specific primary health care: results from the nKPI and OSR collections, AIHW, Australian Government, accessed 31 May 2022.
Bear RA and Stockie S (2014) Patient engagement and patient-centred care in the management of advanced chronic kidney disease and chronic kidney failure, Canadian Journal of Kidney Health and Disease 1:24, doi: 10.1186%2Fs40697-014-0024-7.
Havas K, Douglas C and Bonner A (2017) Person centred care in chronic kidney disease: a cross sectional study of patients’ desires for self management support, BMC Nephrology 18:17, doi: 10.1186%2Fs12882-016-0416-2.
KHA (Kidney Health Australia) (2020a) Chronic kidney disease (CKD) management in primary care, 4th edition, KHA, Melbourne.
KHA (2020b) Estimated glomerular filtration rate (eGFR) fact sheet, KHA, Melbourne.
KHA (2017a) Albuminuria fact sheet, KHA, Melbourne.
KHA (2017b) Calcium and phosphate balance with kidney disease fact sheet, KHA, Melbourne.
Khanam MA, Kitsos A, Stankovich J, Castelino R, Jose M, Kinsman L et al. (2019) Chronic kidney disease monitoring in Australian general practice, Australian Journal of General Practice, 48(3), doi: 10.31128/ajgp-07-18-4630.
NPS MedicineInsight (2020) Clinical review, testing and management of renally cleared medicines among MedicineInsight patients with chronic kidney disease in 2018–2019, NPS MedicineWise, Sydney.