Issue 33 / 31 August 2015

THE less obvious risk factors for chronic kidney disease are underrecognised in Australia, leaving many people undiagnosed and without treatment, according to a leading GP.
Professor Mark Harris, director of the Centre for Primary Health Care and Equity at the University of NSW and spokesperson for the Royal Australian College of General Practitioners, told MJA InSight that GPs were sufficiently aware of chronic kidney disease (CKD) when it came to detecting the major risks.
“By and large, GPs do a good job at recognising people in the very high-risk groups and monitoring these patients.”
However, he said that the regularity of assessment of people who do not present with the most obvious risk factors — that is, having diabetes or being an Indigenous Australian — was lacking.
Professor Harris was commenting on a “Perspectives” article published online today in the MJA which calls for a shift in focus away from treating CKD to “more purposeful prevention”. (1)
The authors said that the first challenge in implementing successful CKD prevention was the low awareness among the general public and primary health care professionals.
To address this problem, Kidney Health Australia had implemented initiatives including a health professional education program, developing guidelines for CKD management in general practice and launching Kidney Health Week. (2)
However, the MJA authors wrote that there was still a long way to go and success in this area would require a joint effort between health care professionals, not-for-profit organisations and government bodies.
They said the second challenge in CKD prevention was the imperfections of the current screening methods, which were based on measurement of both proteinuria and glomerular filtration rate (GFR).
Proteinuria could be affected by factors such as physical activity, posture and timing of urine collection, while GFR was estimated from creatinine-based formulas, which could lead to significant variability in estimated values.
They said that novel markers needed to be developed to better identify individuals at risk of developing CKD and predict the propensity for progression.
Professor David Johnson, director of the Metro South and Ipswich Nephrology and Transplant Service in Queensland, told MJA InSight that the management of CKD in general practice “has improved a lot in recent times due to educational activities, particularly those undertaken by Kidney Health Australia”.
However, he said that data collected by Kidney Health Australia indicated that less than 10% of people with CKD were aware they had the condition. (3)
Professor Johnson said only a small proportion of GPs audited their practice records to detect patients with CKD risk factors, which also reduced the effectiveness of prevention efforts.
While the MJA authors called for the development of better screening tools, Professor Harris said in the meantime GPs should be more alert to the full range of possible risk factors.
“Don’t just look for people with diabetes, or people who are Indigenous. Also look for patients who are over the age of 50 and have hypertension, patients over the age of 40 who smoke, patients who are obese, and patients with a family history of kidney failure”, he said.
Official guidelines and publications could only go so far in raising this awareness, and more detailed direction was needed, he said.
“If an estimated GFR test is done and the levels show up as impaired, then it has to be made clearer to GPs what they then need to do”, Professor Harris said.
“We also need to be more aware of the limitations of the estimated GFR test — what it can do and what it can’t do. For example, it’s limited in the case of acute renal failure.”
The MJA authors said that the third challenge to improved CKD prevention was that among Indigenous Australians the burden of CKD was higher and prevention harder, largely due to risk factors associated with socioeconomic disadvantage.
Professor Johnson said that when it came to screening for and managing CKD in Indigenous Australians, GPs should follow the recommendations developed by the National Aboriginal Community Controlled Health Organisation with the RACGP. (4)
(Photo: Picsfive / shutterstock)

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