Chronic kidney disease

Aeromedical Implications

Effect of aviation on condition

  • Fatigue
  • Sleep deprivation aggravating fatigue
  • Increased cardiac workload during stressful phases of flight potentiating haemodynamic imbalance secondary to fluid shift
  • Hypoxic, hypobaric, low relative humidity flight environment compounding oxygen transfer in affected tissues

Effect of condition on aviation

  • Reduced exertional capacity / G- intolerance due to electrolyte and fluid balance issues
  • Subtle cognitive impairment due to electrolyte changes and renal anaemia
  • Cardiorespiratory compromise (shortness of breath, cardiac stress) due to renal anaemia
  • Physical effects of peripheral oedema

Effect of treatment on aviation

  • Variability of stability in between dialysis treatments
  • Side effects of medication such as steroids and other treatments

Approach to medical certification

Based on condition

  • Stage 1 – eGFR ≥ 90 – No aeromedical concerns
  • Stage 2 – eGFR 60-89 - Not CKD unless haematuria, structural or pathological abnormalities present
  • Stage 3a – eGFR 45-59 – Assess cause / trajectory – requires annual review
  • Stage 3b – eGFR 30-44 – may be unfit for unrestricted certification – refer to CASA
  • Stage 4 – eGFR 15-29 – unlikely fit for certification - refer to CASA
  • Stage 5 – eGFR <15 – unfit for medical certification – refer to CASA
  • Prescence of significant proteinuria may result in aviation disposition classification at one level down

Based on Treatment

  • Acceptable – monitoring only or stable treatment without significant side effects
  • Caution – use of steroids >10mg prednisolone equivalent requires medical certificate holder not to be engaged in safety sensitive duties
  • Renal Transplant – CASA will not consider aeromedical certification for pilots or ATCs until 12 months following transplantation. Recertification will be considered on a case-by case basis
  • Unacceptable – renal dialysis.

Demonstrated Stability

  • Post renal transplant – individualised assessment on return to work and recertification
  • Post changes in treatment – will need to be cleared by CASA.

Risk assessment protocol - Information required

A report from the treating doctor will be required.

  • CASA requires a report from the relevant specialist(s) - e.g., Renal Physician, Cardiologist, Endocrinologist, depending on system involvement, symptoms, and findings of preliminary investigations. The report(s) should detail:
    • Confirmed diagnosis
    • Clinical status
    • Presence, severity, and impact of ongoing symptoms (such as breathlessness, oedema, cognitive symptoms etc)
    • Current treatment
    • Side-effects
    • If clinically indicated or if coronary risk score >14, stress test
    • Results of recent investigations – eGFR (serial results), microalbuminuria, full blood count
    • Progress
    • Prognosis in the short, medium, and longer term
    • Management - Proposed monitoring and follow-up plan. Please detail periodic investigations required.

The investigations listed above under the approach to medical certification must be less than 3 months old at the time of review for certification.

Indicative outcomes

  • Initial notification to CASA and grounding until demonstrated stability and absence of symptoms or complications
  • Unrestricted certification is possible if asymptomatic with absence of or low risk of significant impairment, eGFR>35 and urine microalbumin of <25mg/mmol.

Favourable

  • Absence of symptoms
  • Absence of side-effects from treatment
  • Absence of cardiac, respiratory, neuropsychological, or other organ system involvement.

Unfavourable

  • Ongoing symptoms
  • Further acute kidney injury (AKI) episodes
  • Stage 3b or worse renal failure
  • Proteinuria with urine microalbumin of .25mg/mmol
  • Rapid or unstable trajectory
    • eGFR reduction of >3 ml/min/1.73 m(2)/year
  • Associated anaemia
    • <100g/dL
  • Cognitive impact
  • Dialysis or renal transplant required.

Pilot and Controller Information

  • Annual review will be required
  • Multi-crew or safety pilot restriction may be required for pilots with moderate to severe disease
  • Treatment may impact the ability to exercise the privileges of your medical certificate.

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Disclaimer

The clinical practice guidelines is provided by way of guidance only and subject to the clinical practice guidelines disclaimer.

Online version available at: https://www.casa.gov.au//licences-and-certificates/medical-professionals/dames-clinical-practice-guidelines/chronic-kidney-disease
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