Medicines and the Kidneys
Current medications
- Metformin 500 mg tablet, 1 three times a day
- Empagliflozin 10 mg tablet, 1 daily in the morning
- Perindopril arginine 5 mg tablet, 1 daily in the morning
- Atenolol 50mg tablet, 1 daily in the morning
- Aspirin 100mg (enteric coated) tablet, 1 daily in the morning
- Rosuvastatin 20mg tablet, 1 daily in the morning
- Calcium/Colecalciferol (Ostelin®) 600mg/12.5microg tablet, 1 twice a day
Ben, a 78 year old male, presents for a repeat of his scripts and a BP check. Ben has been a patient of your practice for many years. His long time GP recently retired, and this is the first time you have seen him. Ben is recently widowed and lives independently at home with family and community supports in place.
Ben’s history includes type 2 diabetes, ischaemic heart disease (myocardial infarction with coronary artery stenting 12 years ago) and hypertension. He has osteoarthritis of his knees.
Ben is a reformed smoker (ceased 12 years ago), drinks alcohol occasionally and has no allergies.
On examination Ben appears overweight, weight 94 kg, height 176 cm, BMI 30.3. BP is 148/90 sitting. His heart sounds are normal. Chest is clear and there is no ankle oedema. He has crepitus and reduced range of motion in both knees.
During discussion, Ben states
There is no record of chronic kidney disease in the practice software.
Activity
What reasons do you have to suspect that Ben could have reduced kidney function?
(select all that apply)
a. Diagnosed with CKD or other kidney abnormality
b. Aged 60 years and older
c. First Nations Australians aged 18 years or over
d. BMI > 30 kg/m2
e. Current or former smokers or vapers
f. Family history of kidney failure
g. History of diabetes
h. History of hypertension
i. History of established CVD
j. History of AKI
k. Recent acute illness
l. Recent discharge from hospital
m. Symptoms suggesting an adverse effect of a medicine
You see that Ben’s last kidney health check was 2 years ago, so you ask him if he’d be happy to participate in one today. He agrees.
Knowledge check
Which of the following are the essential components of a kidney health check? (select all that apply)
a. Blood pressure check
b. Estimated glomerular filtration rate
c. Urine albumin/creatinine ratio
d. Urine microscopy
Ben’s BP measurement today is 148/90 mmHg.
You talk to Ben about his use of ibuprofen and explain that it can cause problems in people who have high blood pressure and CVD if used regularly. He shares that he only uses it infrequently “when the weather turns cold”. You advise him to come and see you again if he feels his pain is getting worse and recommend that he could try topical NSAIDs rather than oral if required.
You organize blood testing to assess full blood count, electrolytes and lipids, HbA1c and urine testing to assess uACR.
You review Ben’s previous results. Testing two months ago showed normal potassium and sodium, with elevated creatinine and urea, and eGFR of 45mL/min/1.73m2. The last uACR two years ago showed a normal result.
Get to know the resources available
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The Chronic Kidney Disease (CKD) Management in Primary Care 5th edition provides guidance and clinical tips to help detect, manage, and refer patients with CKD in your practice. |
Based on these results, you determine that Ben has reduced kidney function, classified as stage 3b CKD. You also have concerns regarding his BP and LDL given his history of ischaemic heart disease and diabetes. His diabetes management looks like it could also be improved.
You ask Ben to come in for an appointment to complete his CKD diagnosis, discuss his kidney function and organize a Home Medicines Review (HMR).
You provide Ben with a copy of the Medicines review in chronic kidney disease (CKD) [LC1] brochure and explain the HMR process. He provides his consent. You send an HMR referral to the pharmacist that includes recent lab results and investigations and ask them to specifically review the appropriateness of Ben’s medications in the context of CKD.
Two weeks later you receive an HMR report from the pharmacist which includes the following recommendations:
Activity
Consider the recommendations made in the HMR report – which of these recommendations (if any) would you incorporate into a medication management plan?
What do you consider the highest priority for Ben’s medication management?
Is anything missing that you think is important?
CPD - Review your own performance
To claim up to 2.5 hours of Reviewing Performance (0.5 hours per patient), please complete the following activity after reading the educational materials:
Find up to five of your patients with a diagnosis of hypertension, CVD or diabetes.
For each patient, review their record for their most recent Kidney Health Check, eGFR result, and Medicines Review (see data collection template below).
Actions you could consider from the results of your mini-audit:
- If there is no Kidney Health Check documented within the past 2 years, consider offering them one.
- If a documented Kidney Health Check indicates CKD, make sure the CKD diagnosis has been coded into the practice software.
- If a recent eGFR is less than 60mL/min/1.73m2, consider if this is acute or chronic kidney impairment and review their currently prescribed medicines.
- If there is no medicines review (MBS items 900, 903, 245 and 249) within the past 12 months, consider referring for an HMR or RMMR.
Note: to be eligible to claim 2.5 hours of Measuring Outcomes you must review a minimum of five patients.
Current medications
- Metformin 500 mg tablet, 1 three times a day
- Empagliflozin 10 mg tablet, 1 daily in the morning
- Perindopril arginine 5 mg tablet, 1 daily in the morning
- Atenolol 50mg tablet, 1 daily in the morning
- Aspirin 100mg (enteric coated) tablet, 1 daily in the morning
- Rosuvastatin 20mg tablet, 1 daily in the morning
- Calcium/Colecalciferol (Ostelin®) 600mg/12.5microg tablet, 1 twice a day