Chronic Kidney Disease (CKD)
from –https://assets.kidney.org.au/resources/KHA-CKD-Handbook-5th-Ed-July2024.pdf
Definition
CKD is characterized by abnormalities of kidney structure or function, present for >3 months, with implications for health. Diagnosis requires one or more of the following:
- Decreased eGFR: <60 mL/min/1.73 m²
- Markers of kidney damage, including:
- Albuminuria:
- ACR ≥2.5 mg/mmol (men) or
- ≥3.5 mg/mmol (women)
- Persistent hematuria (after exclusion of urological causes)
- Electrolyte abnormalities due to tubular disorders
- Structural abnormalities detected by imaging (scarring, polycycstic kidneys)
- Histological abnormalities identified by biopsy
- Albuminuria:
Epidemiology & Causes
CKD more common in:
- Women with T2DM
- Aboriginal and Torres Strait Islander peoples
- Some non-European ethnic groups
Early treatment reduces morbidity and mortality.
Systolic BP is a key predictor of progression.
CKD in diabetes is often asymptomatic – rely on labs.
- Diabetic nephropathy – 36%
- Glomerulonephritis – 19%
- Hypertension – 12%
- Polycystic kidney disease – 5%
- Reflux nephropathy
- Tubulointerstitial disease – (e.g. NSAIDs, lithium, heavy metals)
- Plasma cell dyscrasias – Myeloma, light chain deposition, amyloidosis
- Unknown – 5%
Risk Factors
- Non-modifiable:
- Age ≥60 years
- Family history of kidney disease
- Aboriginal or Torres Strait Islander descent
- Modifiable:
- Diabetes mellitus
- Hypertension
- Smoking
- Obesity (BMI ≥30 kg/m²)
- Cardiovascular disease
- History of acute kidney injury (AKI)
- Exposure to nephrotoxic agents
📉 eGFR decreases ~8 mL/min/1.73 m² per decade after age 30
⚠️ eGFR <60 still carries increased risk of CVD and CKD progression
Clinical Features
CKD is often asymptomatic until advanced stages (≥ Stage 4–5).
Possible symptoms:
- Fatigue, malaise, anorexia, nausea
- Nocturia, pruritus, restless legs
- Dyspnoea, volume overload
- Hypertension
- Haematuria
Screening Recommendations
- BP
- UEC: If eGFR < 60mL/ min/1.73m2 repeat within 7 days
- ACR – first morning void, If ACR positive, require 2 further samples over 2 months
General Population
| Risk Category | Screening Frequency |
|---|---|
| Diabetes, Hypertension | Annually |
| Obesity, Smoking, FHx, ATSI | Every 2 years |
| Age ≥ 60 without other risk factors | No routine screening recommended Whilst being aged 60 years of age or over is considered to be a risk factor for CKD, in the absence of other risk factors it is not necessary to routinely assess these individuals for kidney disease. |
Aboriginal and Torres Strait Islander Peoples
- Ages 18–29 without risk factors: Annual screen (as part of MBS 715)
- With ≥1 risk factor: Screen every 2 years (ACR, eGFR, BP)
🧪 ACR positive: Repeat twice over 3 months (preferably first-void)
🧪 eGFR < 60: Repeat within 7 day
Investigations
Urine
- MSU MCS – Rule out infection
- Microscopy – Dysmorphic RBCs, casts, crystals
- Urine ACR – First morning void preferred
- Urine immunoelectrophoresis – Bence-Jones proteins
Bloods
- FBC, CRP, ESR
- eLFTs, CMP, HCO₃⁻
- Lipids, fasting glucose/HbA1c
- B12, folate, iron studies, PTH
- Autoimmune screen (ANA, ENA, C3/C4, ESR, ANCA, anti-GBM)
- serum protein electrophoresis (SPEP) and urine protein electrophoresis (UPEP) – If aged >40 with suspicion of myeloma
- Hepatitis B/C, HIV, syphilis serology (if not performed in past 12 months)
Imaging
- Renal ultrasound – Assess size, structure, obstruction
eGFR (Estimated Glomerular Filtration Rate)
- Best overall marker of kidney function (via CKD-EPI equation, validated across ethnicities).
- Automatically reported with serum creatinine in adults ≥18 years.
- More sensitive than serum creatinine alone — up to 50% kidney function may be lost before creatinine rises.
When eGFR May Be Unreliable / Misleading:
- Acute changes (e.g. AKI)
- On dialysis
- Recent cooked meat consumption (<4 hours before test)
- High or low protein intake, vegetarian diet, creatine supplements
- Extremes of body size
- Muscle conditions (paraplegia, amputees → overestimation; high muscle mass → underestimation)
- <18 years of age
- Severe liver disease
- eGFR >90 mL/min/1.73m²
- Drugs affecting creatinine (e.g., trimethoprim)
- Pregnancy
- Minor changes (≤15%) may reflect lab or physiological variability
eGFR and Drug Dosing
- Valid for drug clearance estimation; check product info
- Adjust for BSA in extremes of body size
- Use therapeutic monitoring for narrow therapeutic index drugs
eGFR in Pregnancy
- Not recommended
- Use serum creatinine instead
Clinical Tip:
- If eGFR <60 mL/min/1.73m²:
- Repeat in 7 days to exclude AKI
- Repeat at 3 months to diagnose CKD
Albuminuria / Urine Albumin:Creatinine Ratio (uACR)
| Category | ACR (mg/mmol) | Albumin excretion (mg/day) | PCR (mg/mmol) | Protein excretion (mg/day) | Dipstick |
|---|---|---|---|---|---|
| Microalbuminuria | M: 2.5–25 F: 3.5–35 | 30–300 | M: 4–40 F: 6–60 | 50–500 | Trace to +1 |
| Macroalbuminuria | M: >25 F: >35 | >300 | M: >40 F: >60 | >500 | ≥ +1 |
- Detects albuminuria, an early and often missed CKD marker
- Predicts risk of kidney failure and cardiovascular disease
- uACR more sensitive than uPCR (especially for microalbuminuria)
- Dipstick urine protein tests are not recommended
- ≥2 abnormal uACRs (≥3.0 mg/mmol) over 3 months = albuminuria
Testing Recommendations
- Use first-void urine sample for best accuracy
- Random spot acceptable if first-void not practical
- Positive uACR → repeat on first-void sample
- 24-hour collection not routinely needed
Conditions that falsely elevate albuminuria:
- UTI
- High dietary protein
- CHF
- Fever
- Recent heavy exercise (<24h)
- Menstruation
- Genital infection/discharge
- NSAIDs
Albuminuria in Pregnancy
- uACR thresholds not validated — interpret with caution
Staging of CKD
Based on eGFR
- G1: ≥90 mL/min/1.73 m² (normal or high)
- G2: 60–89 mL/min/1.73 m² (mildly decreased)
- G3a: 45–59 mL/min/1.73 m² (mild to moderate decrease)
- G3b: 30–44 mL/min/1.73 m² (moderate to severe decrease)
- G4: 15–29 mL/min/1.73 m² (severely decreased)
- G5: <15 mL/min/1.73 m² (kidney failure)
Based on Albuminuria (ACR)
- A1: <3 mg/mmol (normal to mildly increased)
- A2: 3–30 mg/mmol (moderately increased)
- A3: >30 mg/mmol (severely increased)
Management Strategies
Lifestyle Modifications
| Parameter | Treatment Goal |
|---|---|
| Nutrition and Diet | • Eat a healthy diet (vegetables, fruits, wholegrains, legumes, dairy, lean meats, fish, plant proteins) • Limit salt to <5g/day • Avoid ultra-processed foods and sugary drinks • Drink water to satisfy thirst |
| Weight Management | • BMI <25 kg/m² (Asians <23 kg/m²) • Waist circumference: <94 cm (men), <90 cm (Asian men), <80 cm (women including Asian) |
| Physical Activity | • Be active most days, ideally daily • Aim 2.5–5 hrs/week of moderate activity • Include strength training ≥2x/week • Any activity better than none |
| Smoking/Vaping | • Do not smoke or vape • Offer counselling, NRT or meds • Refer to Quitline 13 7848 |
| Alcohol | • Reduce alcohol • General guideline: ≤10 standard drinks/week and ≤4/day • No CKD-specific safe alcohol threshold |
| Immunisation | • Recommend: Influenza, Pneumococcal, COVID-Influenza: annually Pneumococcal: every 5 years COVID-19: per current guidelines Herpes Zoster: as per NIP |
Pharmacological Interventions
TARGET parameters
| Hypertension | • Maintain BP <130/80 mmHg in all CKD patients |
| Glycaemic Control | • Fasting BGL: 6–8 mmol/L • Postprandial BGL: 8–10 mmol/L • HbA1c ≤53 mmol/mol (≤7%) • Individualise per patient factors |
| Albuminuria | • Aim ≥30% reduction in uACR |
| Lipids | • No absolute cholesterol target • Use statin ± ezetimibe if: – eGFR ≥15 + CVD risk ≥10% – First Nations Australians + CVD risk ≥5% |
| Potassium | • Maintain serum potassium ≤6.0 mmol/L |
Monitoring and Follow-up
- Frequency:
- Low risk: Annual review.
- Moderate risk: Every 6 months.
- High risk: Every 3 months.
- Assessments:
- eGFR and urine ACR.
- Blood pressure.
- Medication review.
- Cardiovascular risk assessment.
Patient Education and Support
- Inform about CKD progression: Emphasize the importance of lifestyle and medication adherence.
- Discuss potential complications: Cardiovascular disease, anemia, bone mineral disorders.
- Encourage self-management: Blood pressure monitoring, dietary choices, and recognizing signs of disease progression.
Contraception and Pregnancy in CKD
- Pregnancy increases kidney workload and may:
- Unmask undiagnosed CKD
- Worsen existing CKD
- CKD increases pregnancy risks, especially hypertensive disorders.
- Fertility may be preserved despite advanced disease or dialysis.
- Unexpected pregnancy is possible even with ESKD.
Recommendations
- Preconception counselling essential.
- Contraception should be offered to all sexually active individuals of reproductive age with CKD.
- Prioritise effective contraception if:
- On teratogenic drugs
- Have uncontrolled HTN or CKD
- Post kidney transplant
- Avoid oestrogen if:
- HTN, thrombotic history, proteinuria, lupus
- Preferred methods:
- IUDs
- Permanent options (vasectomy, tubal ligation) if no future pregnancy desired
- Refer to maternal medicine, obstetric nephrology, or high-risk pregnancy team:
- Preconception ideally
- At minimum, early in pregnancy
CKD in Older People
- Individualised approach is key.
- Consider:
- Functional status
- Life expectancy
- Treatment goals (quality of life vs. survival)
- eGFR more accurate than creatinine alone in elderly.
- eGFR <60 is not normal for age—still indicates risk.
Dialysis vs. Conservative Management
- In elderly with multiple comorbidities, dialysis may not improve survival.
- Decision aid tools (e.g., My Kidneys My Choice) support shared decision-making.
Referral Guidance
- Referral to nephrologist if:
- eGFR <30 mL/min/1.73m²
- Anaemia possibly due to CKD
- Suspected glomerulonephritis or systemic disease
- Electrolyte imbalances (e.g., hyperkalemia)
- Resistant hypertension
- Hematuria with proteinuria
- Persistent significant albuminuria (ACR >30 mg/mmol)
- Rapid decline in eGFR (>5 mL/min/1.73 m² per year)
- Can manage in primary care if:
- eGFR ≥30
- Microalbuminuria present
- BP controlled
- Discuss with specialists via phone/email for shared care.
Medication Management in CKD and Older Adults
- Dose adjustments needed with declining eGFR.
- Monitor for side effects (increased risk in elderly).
- Polypharmacy risk: falls, confusion, decline.
- Support with:
- Home Medicines Reviews (HMR)
- Residential Medication Management Reviews (RMMR)
Avoid nephrotoxins
Commonly Prescribed Drugs That May Harm Kidney Function in CKD
- Lithium
- Risk: Nephrogenic diabetes insipidus, chronic tubulointerstitial nephritis
- Requires monitoring of serum levels and renal function
- Aminoglycosides (e.g., gentamicin, tobramycin)
- Risk: Acute tubular necrosis (ATN)
- Especially toxic with prolonged use or in dehydration
- NSAIDs / COX-2 inhibitors
- Risk: Afferent arteriole constriction → ↓ GFR
- May lead to AKI, especially in hypovolaemic states
- Avoid combination with ACEi/ARB + diuretic (“Triple Whammy”)
- ACE Inhibitors / ARBs
- Risk: Efferent arteriole dilation → ↓ intraglomerular pressure
- Can cause a reversible decline in eGFR
- Monitor urea, creatinine, potassium after initiation
- Diuretics (loop or thiazide)
- Risk: Hypovolaemia, electrolyte disturbances, pre-renal AKI
- Metformin
- Risk: Lactic acidosis in patients with significant renal impairment or during dehydration
- Avoid if eGFR <30 mL/min/1.73 m²
- Sulfonylureas (e.g., gliclazide)
- Risk: Hypoglycaemia, especially in reduced renal clearance
- SGLT2 inhibitors (e.g., dapagliflozin, empagliflozin)
- Risk: Osmotic diuresis, volume depletion, transient eGFR dip
- Can lead to AKI in setting of acute illness or dehydration
⚠️ Sick Day Rule: SADMANS Acronym
These medications should be withheld temporarily during acute illness (e.g. fever, vomiting, diarrhoea, reduced oral intake) to prevent AKI:
| Letter | Drug Class | Example Medications |
|---|---|---|
| S | Sulfonylureas | Gliclazide, glibenclamide |
| A | ACE Inhibitors | Ramipril, perindopril |
| D | Diuretics | Furosemide, indapamide |
| M | Metformin | Metformin |
| A | ARBs | Irbesartan, candesartan |
| N | NSAIDs | Ibuprofen, celecoxib |
| S | SGLT2 inhibitors | Empagliflozin, dapagliflozin |
Clinical Tip: “Triple Whammy” AKI Risk
- Concurrent use of:
- NSAID
- ACE inhibitor or ARB
- Diuretic
- Increases risk of acute kidney injury, especially in dehydration or intercurrent illness.
MEDICATIONS
BP control
is crucial in slowing CKD progression and reducing cardiovascular risk.
- Target BP:
- <140/90 mmHg (general CKD population)
- <130/80 mmHg (if diabetes or significant albuminuria)
Stepwise Pharmacological Approach
ACE inhibitor (ACEi) or Angiotensin II receptor blocker (ARB) = Step 1: First-Line Therapy
- ACE inhibitor (ACEi) or Angiotensin II receptor blocker (ARB)
- Initiate and up-titrate to maximum tolerated dose
- Prescribe for all CKD patients with:
- ACR > 3 mg/mmol and comorbid diabetes, IHD, or hypertension
- ACR > 30 mg/mmol (proteinuria)
- Therapeutic Goal: ≥ 50% reduction in albuminuria
Step 2: Add-On Antihypertensives (if BP target not achieved)
- Calcium Channel Blocker (CCB)
- Safe and effective in CKD.
- Especially useful for:
- Systolic hypertension
- Angina
- Elderly patients
- Thiazide Diuretic
- Effective across CKD stages, though less so with eGFR <30 (lose efficacy at eGFR <30, but may be useful for BP and K⁺ control)
- Temporarily withhold during intercurrent illness/dehydration
- e.g., indapamide or hydrochlorothiazide
Step 3: Consider Other Agents
- Loop Diuretic – e.g., Frusemide
- Effective at all stages of CKD, including eGFR <30 mL/min/1.73m²
- Dosing:
- Typical: 20–120 mg/day
- Can increase to up to 500 mg/day if needed
- Divide doses >80 mg/day for better efficacy
- Beta Blocker
- Use in CAD, tachyarrhythmias, or heart failure
- Avoid in asthma or heart block
- MRA
- Steroidal MRAs (e.g. spironolactone, eplerenone)
- Can be used in heart failure or hypertension
- Use cautiously in CKD and with RAS inhibitors → monitor for hyperkalaemia, eGFR drop
- Non-Steroidal MRAs (e.g. finerenone)
- Safer alternative in CKD + type 2 diabetes
- Do not combine steroidal + non-steroidal MRAs
- Monitor K⁺ closely
- Steroidal MRAs (e.g. spironolactone, eplerenone)
SGLT2 Inhibitor
- Dapagliflozin – 10 mg taken once daily, with or without food.
- Next Step After Stabilised RAAS Blockade
- Recommended for people with CKD and proteinuria, with or without diabetes.
- Benefits:
- slows CKD progression
- reduces CV risk (DAPA-CKD trial)
- Indications:
- eGFR: 25–75 mL/min/1.73m²
- ACR: 22.6–565 mg/mmol
- Do not initiate if eGFR <25 mL/min/1.73m²
- Reversible eGFR drop expected:
- Greatest drop at ~4 weeks, then stabilises.
- Routine eGFR testing post-initiation not necessary unless symptomatic.
- Consider reducing diuretics or antihypertensives at initiation due to osmotic diuresis.
Non-Steroidal Mineralocorticoid Receptor Antagonist (e.g. Finerenone)
- Use in people with CKD and albuminuria associated with type 2 diabetes.
- Do not initiate if:
- eGFR <25 mL/min/1.73m²
- Serum potassium >5.0 mmol/L
- Monitor for hyperkalaemia
GLP-1 Receptor Agonist (GLP-1 RA)
- Indicated for people with CKD and type 2 diabetes
- Benefits:
- Reduces albuminuria
- Cardiovascular protection
- Not recommended in patients with kidney failure
Clinical Tips
- Temporarily withhold the following drugs during acute illness (e.g., sepsis, hypotension, dehydration):
- ACE inhibitors
- ARBs
- SGLT2 inhibitors
- Diuretics
- Check eGFR within 2 weeks of initiating ACEi/ARB:
- If <25% drop → continue
- If >25% drop → cease and refer nephrology
💊 ACEi/ARB
🔬 Physiological Background: Renal Autoregulation
- Glomerular filtration is maintained via a balance between:
- Afferent arteriole – delivers blood into the glomerulus
- Efferent arteriole – drains blood from the glomerulus
- Angiotensin II preferentially constricts the efferent arteriole:
- Maintains intraglomerular pressure
- Helps preserve GFR during low perfusion states (e.g., dehydration, heart failure, CKD)
🧪 Mechanism of Action: ACEi/ARB
- ACEi/ARB inhibit the renin–angiotensin–aldosterone system (RAAS), leading to:
- Efferent arteriole vasodilation
- ↓ Intraglomerular pressure
- ↓ GFR (initial, hemodynamic effect)
📈 Renal and Cardiovascular Benefits
| Benefit | Mechanism | Clinical Impact |
|---|---|---|
| ↓ Glomerular hypertension | Efferent vasodilation | Protects against hyperfiltration injury |
| ↓ Proteinuria | Reduced glomerular capillary pressure | Slows progression of nephron loss |
| ↓ Fibrosis/inflammation | RAAS inhibition | Preserves structural kidney integrity |
| ↓ BP and CV risk | Systemic RAAS blockade | ↓ MI, stroke, CV mortality (independent of BP control) |
🛡️ CKD-Specific Outcomes
Delays progression to end-stage kidney disease (ESKD)
- Reduces albuminuria
- Target: ≥50% reduction in urine ACR
- Degree of ACR reduction correlates with slower eGFR decline
- Prevention of albuminuria onset
- Type 1 or 2 diabetes: prevents microalbuminuria onset
- Slows progression from micro- to macroalbuminuria in normotensive and hypertensive diabetics
- Lowers cardiovascular event rates in CKD populations
🔄 Expected eGFR Changes After Initiation
- Up to 25% reduction in eGFR (or ~30% ↑ in creatinine) is:
- Expected, transient, and due to hemodynamic changes
- Usually stabilises within 1–2 weeks at a new baseline
- Do not cease ACEi/ARB based on eGFR drop alone
- Monitor:
- Serum creatinine and potassium 1–2 weeks post-initiation or after dose increase
⚠️ When to Be Concerned
- >25–30% fall in eGFR may indicate:
- Bilateral renal artery stenosis
- Volume depletion/dehydration
- NSAID co-use (i.e., triple whammy with diuretic)
- Severe heart failure
- Advanced CKD (Stage 4–5)
- Serum potassium: Acceptable up to 6.0 mmol/L if stable over 2 months
| Parameter | Acceptable Threshold |
|---|---|
| eGFR reduction | ≤25% from baseline |
| Serum potassium | ≤6.0 mmol/L (monitor closely) |
| If >25% eGFR decline | Cease ACEi/ARB and consider referral |
❌ Contraindications
- Absolute:
- History of angioedema
- Pregnancy (Category D – teratogenic)
- Bilateral renal artery stenosis
- ACEi-induced hypersensitivity
- Relative:
- Significant aortic stenosis or hypertrophic cardiomyopathy
- Dry cough (ACEi only – affects ~10%)
- Hyperkalaemia
- If intolerant to ACEi → Switch to ARB
- Do not combine ACEi + ARB
- ↑ Risk of AKI and hyperkalaemia
- No added benefit (as shown in ONTARGET trial)
🩸 Glycaemic Control in CKD
Glycaemic Targets in CKD
Blood Glucose Levels (BGL)
- Fasting BGL: 6–8 mmol/L
- Postprandial BGL: 8–10 mmol/L
HbA1c
- General target: ≤53 mmol/mol (≤7%)
- Acceptable range: 48–58 mmol/mol (6.5–7.5%)
- Individualise based on:
- Comorbidities
- Disease duration
- Life expectancy
- Vascular complications
- Unreliable in:
- Iron deficiency (falsely elevated)
- Anaemia (falsely lowered)
- Consider lower targets where appropriate
Management Considerations
- Optimal glycaemic control reduces micro- and macroalbuminuria and nephropathy risk.
- CKD increases hypoglycaemia risk:
- ↓ renal clearance of insulin and hypoglycaemic drugs
- Medication doses may need adjustment or cessation as CKD progresses.
- Educate patients on lifestyle and “sick day” rules (withhold nephrotoxic/hypoglycaemia-inducing drugs during illness).
Medication Summary for Diabetes in CKD
| Class | Drug Examples | CKD Dosing Guidance | Key Points |
|---|---|---|---|
| Metformin | Metformin | – Full dose if eGFR >60 – Reduce dose if eGFR 30–60 – Avoid if eGFR <30 | – Temporarily withhold during illness – Risk of lactic acidosis |
| SGLT2 inhibitors | Dapagliflozin, Empagliflozin, Ertugliflozin | – Do not initiate if eGFR <25–30 (varies) – Cease in ESKD or dialysis | – Renal + CV benefit – Risk: eDKA, fungal infections |
| Non-Steroidal MRA | Finerenone | – Avoid if eGFR <25 or K⁺ >5.0 mmol/L – Cease if K⁺ >5.5 mmol/L | – Not for diabetes unless CKD present – Monitor K⁺ closely |
| DPP-4 inhibitors | Linagliptin, Sitagliptin, Saxagliptin, Vildagliptin, Alogliptin | – Linagliptin: No dose adjustment – Others: Reduce dose if eGFR <45–60 | – Caution if pancreatitis hx – ↑ risk of hypoglycaemia with sulfonylureas |
| Sulfonylureas | Gliclazide, Glibenclamide | – Reduce dose if eGFR <30 – Avoid glibenclamide in CKD | – ↑ Hypoglycaemia risk as eGFR declines |
| GLP-1 RA | Semaglutide, Dulaglutide | – No adjustment unless eGFR <15 – Not recommended in kidney failure | – Potential CV and renal benefits – Limited data in eGFR <30 |
| Insulin | All insulins | – Adjust dose as needed – Monitor BGL closely | – ↑ Hypoglycaemia risk with declining eGFR |
Medications requiring dose reduction
- Pharmacological management for CKD also includes adjusting doses of medicines cleared by the kidneys to reduce adverse effects
- Dose reduction or cessation of medicines cleared by the kidneys is generally required once eGFR is < 60 mL
- GFR can be assessed using serum creatinine-based formulae.
- Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI)
- But for extremes of body weight unless it is first corrected to the actual GFR for that patient
| CKD-EPI eGFR. × Individual’s body surface area (BSA) = eGFR result in mL/min 173 BSA = 0.007184 × Weight in kg^0.425 × Height in cm ^0.725 (Du Bois formula) |
| Drug Class | Examples | Notes |
|---|---|---|
| Antivirals | Acyclovir, Tenofovir | High renal clearance, risk of neurotoxicity or nephrotoxicity |
| Benzodiazepines | Midazolam, Lorazepam | Accumulation may lead to sedation, confusion |
| Opioids | Morphine, Codeine, Tramadol | Use with caution; prefer fentanyl or buprenorphine if severe CKD |
| Hypoglycemic agents | ||
| DPP-4 inhibitors | Linagliptin, Sitagliptin, Saxagliptin, Vildagliptin, Alogliptin | – Linagliptin: No dose adjustment – Others: Reduce dose if eGFR <45–60 – Caution if pancreatitis history – ↑ Hypoglycaemia with sulfonylureas |
| GLP-1 RA | Semaglutide, Dulaglutide | – No adjustment unless eGFR <15 – Not recommended in ESKD – CV and renal benefit – Limited data in eGFR <30 |
| Sulfonylureas | Gliclazide, Glibenclamide | – Reduce dose if eGFR <30 – Avoid glibenclamide in CKD – ↑ Hypoglycaemia risk as renal function declines |
| Metformin | – | eGFR > 45: no dose change eGFR 30–45: max 1g/day eGFR < 30: avoid |
| Insulin | – | Reduced renal clearance → increased risk of hypoglycaemia – Adjust dose based on renal function – Monitor BGL closely |
| Cardiac medications | Digoxin, Sotalol, Atenolol | Require close monitoring; risk of bradycardia, arrhythmias |
| Diuretics | Thiazides, K⁺-sparing (e.g. amiloride) | Risk of hyperkalemia and reduced efficacy in advanced CKD |
| Anticoagulants | Enoxaparin (LMWH), Fondaparinux | Require dose adjustment or monitoring of anti-Xa levels |
| Psychotropics / Anticonvulsants | Lithium, Gabapentin, Pregabalin | Accumulate in CKD; risk of CNS toxicity |
| Gout medications | Allopurinol, Colchicine | Reduce dose to prevent bone marrow suppression and neuromyopathy |
🔴 Acute Kidney Injury (AKI)
➤ Key Concepts
- AKI is common and associated with high morbidity/mortality.
- CKD is a major risk factor for AKI.
- AKI can lead to progression of CKD, kidney failure, and death.
➤ Risk Factors
Pre-existing:
- CKD
- Diabetes
- Cardiopulmonary/liver disease
- Cancer
- Anaemia
- Advanced age
Potentially modifiable exposures:
- Pre-renal: Hypovolaemia, hypotension, blood loss, shock
- Intrinsic: Drug toxicity, critical illness
- Post-renal: Obstruction
➤ AKI Prevention and Management
| Phase | Actions |
|---|---|
| Identifying Risk | – All CKD stage 3–5 patients are high risk – Avoid nephrotoxins (NSAIDs, aminoglycosides) – Apply sick day rule for ACEi/ARB/diuretics in illness |
| Diagnosis | – ↑ Creatinine ≥1.5x baseline in <7 days OR – Oliguria (reduced urine output) |
| During AKI | – Identify and treat the cause – Review meds & fluid status – Consult nephrology early |
| Post-AKI | – Repeat Kidney Health Check at 3 months, then annually × 3 yrs – Educate on AKI prevention – Record episode in medical records |
➤ Medications to Withhold During Illness (↓ fluid intake, vomiting, dehydration):
- ACEi
- ARBs
- NSAIDs
- Diuretics
- Metformin
- Sulfonylureas
- SGLT2 inhibitors
🟡 Kidney Cysts
➤ Simple Cysts
- Very common (~10% prevalence), benign, often incidental.
- Features:
- Not inherited
- Asymptomatic
- Increases with age
- Not associated with kidney failure
➤ Refer/Investigate if:
- Multiple or bilateral cysts
- Complex cysts (solid or septated)
- Symptoms: pain, haematuria, infection
- Rapid growth or malignancy suspicion
🟠 Polycystic Kidney Disease (PKD)
➤ Autosomal Dominant PKD (ADPKD)
- Most common inherited kidney disorder
- ~10% cases occur without family history
- May cause progressive CKD
➤ Ultrasound Diagnostic Criteria
| Age | Diagnostic Criteria |
|---|---|
| 15–39 yrs | ≥3 cysts total (unilateral/bilateral) |
| 40–59 yrs | ≥2 cysts in each kidney |
| ≥60 yrs | ≥4 cysts in each kidney |
➤ Management of ADPKD
- Refer early to nephrologist
- Assess family history & progression risk
- Manage HTN, cyst growth, eGFR decline
- Evaluate for complications (e.g., haematuria, infection)
- Consider genetic testing
- Consider MRA for cerebral aneurysm screening (if family history)
- Tolvaptan (PBS listed): for Stage 2–3 rapidly progressing ADPKD
🧊 Kidney Stones
➤ Epidemiology
- Lifetime risk: ~10% men, ~3% women
- Most common: calcium oxalate/phosphate
- Recurrence risk:
- 5–10% per year
- 30–50% within 5 years
➤ Stone Prevention
- Cannot dissolve existing stones
- Goals: Correct urine chemistries and reduce risk
- Refer to dietitian for:
- 3–6-month dietary trial before medications
- Encourage ≥2 L/day urine output
- ↑ Potassium, phytates (nuts, legumes)
- Maintain normal calcium intake
- ↓ Oxalate (spinach, tea), animal protein, sucrose, Na⁺, supplements
➤ Drug Options
- Allopurinol: for hyperuricaemia
- Citrate: for hypocitraturia
➤ Stone Workup
- Serum labs: calcium, uric acid, PTH
- Stone analysis (if passed)
- 24-hour urine collection: volume, calcium, oxalate, citrate, uric acid
➤ Acute Stone Management
- Most <5 mm stones can be passed
- Use alpha-blockers: e.g., prazosin or tamsulosin
- Urgent referral if:
- Infection
- Large stone
- Obstructive symptoms
- Single kidney
CKD Complications and Management
| Complication | Summary | Management Strategies |
|---|---|---|
| Metabolic Acidosis | Common with eGFR <30; ↓ acid excretion and HCO₃⁻ production | – Sodium bicarbonate 840 mg OD-BD → titrate to normalise HCO₃⁻ – Limit dose to avoid fluid overload – Base-producing diet (fruit/vegetables) |
| Albuminuria | Strong prognostic marker for CKD/CVD progression | – ACEi or ARB to max tolerated dose – Add SGLT2i – In T2DM: consider finerenone and/or GLP-1 RA |
| Anaemia | Begins at eGFR <60 due to ↓ EPO, iron, and inflammation | – Target Hb 100–115 g/L – Correct iron (Ferritin >100 / >200 if on ESA; TSAT >20%) – ESA only via nephrologist |
| Depression | Affects ~20% CKD; worsens QOL and adherence | – Screen with DASS-21/K10 – SSRIs preferred – Address modifiable factors (sleep, nutrition, dialysis) – GP Mental Health Plan referral |
| Haematuria | May be glomerular or non-glomerular (UTI, cancer, menstruation, stones) | – Confirm with urine microscopy – Refer to urology or nephrology as appropriate – Annual monitoring if isolated in <40s |
| Complication | Summary | Management Strategies |
|---|---|---|
| Hyperuricaemia | Common with CKD/metabolic syndrome; may cause gout | – Allopurinol 50–100 mg/day (↓ dose with ↓ eGFR) – Avoid colchicine if eGFR <10; reduce dose if eGFR <50 – Low-dose prednisolone in flares – No benefit for CKD alone without gout |
| Hyperkalaemia | Common with CKD + RAS inhibitors/MRA; risk of arrhythmia if K⁺ >6.5 mmol/L | Target K⁺: ≤6.0 mmol/L Risks ↑ with RAS inhibitors, MRAs If K⁺ 6.0–6.5: Diet: low K⁺, avoid salt substitutes Correct acidosis Use potassium-wasting diuretics Consider resins (e.g., SPS, patiromer) If K⁺ >6.5: Emergency referral due to arrhythmia risk |
| Lipids | CKD shows ↑ triglycerides, ↓ HDL; LDL often normal | Characteristic pattern: ↑triglycerides, ↓HDL, normal LDL Management: Statin (+/- ezetimibe) if eGFR ≥15 and CVD risk ≥10% For First Nations patients: threshold ≥5% No target lipid level recommended |
| Malnutrition | Anorexia in CKD contributes; linked to poor prognosis | Related to anorexia and inflammation Management: – Refer to dietitian – Use screening tools for appetite, unintentional weight loss |
| Mineral-Bone Disorder (CKD-MBD) | Begins when eGFR <60; ↓ vitamin D, ↓ calcium, ↑ phosphate, ↑ PTH | – Nephrology referral for CKD stage 3–5 – Monitor calcium, phosphate, PTH – Consider DEXA if result affects management – Avoid calcium overload – Use calcitriol if advanced CKD and hypocalcaemia |
| Complication | Summary | Management Strategies |
|---|---|---|
| Oedema | Common in advanced CKD due to fluid overload, sodium retention, or nephrotic syndrome | Assess for: – Nephrotic syndrome – CHF – Sodium excess – Medications (e.g., CCBs) Management: Mild: elevate legs, reduce sodium, compression stockings Moderate–severe: loop ± thiazide diuretics (adjust for eGFR) Refractory: consider dialysis initiation |
| Pain (CKD-related) | Pain is often multifactorial (neuropathic, nociceptive) and affects QOL | – Step 1: Paracetamol 1g QID (safe) – Step 2: Codeine or tramadol (avoid if eGFR <20) – Step 3: Strong opioids with renal dosing (avoid morphine if eGFR <20) – Neuropathic pain: gabapentin/pregabalin (adjust dose), TCAs (e.g., amitriptyline), duloxetine – Refer to pain/palliative care team if refractory |
| Pruritus | Affects up to 70% with CKD stage 4–5; multifactorial origin | Exclude secondary causes (e.g., skin, calcium/phosphate imbalance) Non-drug: moisturisers, cool showers, avoid irritants Pharmacologic: = Gabapentin (if co-existing restless legs) = Topical capsaicin = UVB therapy (dermatology) = Difelikefalin (kappa opioid agonist for dialysis patients) |
| Complication | Summary | Management Strategies |
|---|---|---|
| Muscle Cramps | Common in advanced CKD; may be due to electrolyte imbalances or volume depletion | – Correct electrolyte abnormalities (e.g., calcium, magnesium, sodium) – Ensure adequate hydration – Limited evidence for magnesium supplementation effectiveness |
| Restless Legs Syndrome (RLS) | Frequently co-occurs with uraemic pruritus; often under-recognised | – First-line: Gabapentin or pregabalin (dose adjust in CKD) – Optimise iron stores (TSAT >20%, ferritin >200 mcg/L) – Ensure adequate dialysis in ESKD – Rule out contributing factors (e.g., anaemia) |
| Constipation | Common due to reduced mobility, medications (e.g., phosphate binders, opioids), low fluid/fibre intake | – Increase dietary fibre if safe (assess for potassium/phosphate content) – Osmotic or stimulant laxatives (avoid phosphate-based laxatives) – Manage contributing medications (e.g., opioids) |
| Cognitive Impairment / Delirium | Common in advanced CKD and dialysis; multifactorial | – Optimise medication regimen to reduce polypharmacy – Assess for contributing factors (electrolytes, uremia, medications) – Consider formal cognitive assessment and geriatric referral where appropriate |
| Falls & Frailty | Common due to sarcopenia, poor nutrition, polypharmacy, orthostatic hypotension | – Screen regularly (e.g., TUG test) – Adjust antihypertensives if symptomatic – Address sarcopenia: physical therapy, protein intake – Home medication review to address polypharmacy |
Metabolic Acidosis in CKD
Pathophysiology
- Occurs when eGFR <30 mL/min/1.73m²
- Due to:
- ↓ Renal acid excretion
- ↓ Bicarbonate regeneration
- Leads to:
- Bone demineralisation
- Increased protein catabolism
- Associated ↑ morbidity
Treatment Target
- Maintain serum HCO₃⁻ >22 mmol/L
Management
- Sodium bicarbonate (SodiBic 840 mg):
- Start: 1 capsule once or twice daily
- May titrate to 2 capsules twice daily
- Monitor and adjust based on bicarbonate level
- Precautions:
- Monitor fluid status – high doses risk fluid overload
- Sodium load may worsen hypertension
Albuminuria in CKD
Prognostic Significance
- Albuminuria correlates with:
- CKD severity
- Risk of progression to ESKD
- Cardiovascular risk
Treatment Target
- Aim for ≥50% reduction in urine ACR
Management
- ACE inhibitor or ARB:
- First-line to reduce albuminuria and slow CKD progression
- Salt restriction:
- ↓ Sodium intake enhances antiproteinuric effect of ACEi/ARB
- Spironolactone (on specialist advice):
- Can reduce albuminuria further
- Monitor potassium regularly
Anaemia of CKD
📉 Pathophysiology
- Common when eGFR <60 mL/min/1.73m²
- Causes:
- ↓ Erythropoietin production
- Iron deficiency
- ESA resistance
Targets
| Parameter | Target Before ESA | Target After ESA |
|---|---|---|
| Hb | Trial iron first if <100 g/L | Maintain 100–115 g/L |
| Ferritin | >100 µg/L | 200–500 µg/L |
| TSAT | >20% | 20–30% |
Management
- IV iron trial before ESA if:
- Ferritin <100 µg/L or TSAT <20%
- Erythropoiesis-Stimulating Agents (ESAs):
- Consider if Hb <100 g/L despite adequate iron
- Avoid overtreatment (risk of thrombosis/stroke)
Hyperparathyroidism and Increased Fracture Risk in CKD:
🔍 Biochemical Targets
- Phosphate (PO₄): Keep within 0.8–1.5 mmol/L
- Calcium (Ca): Maintain within 2.2–2.6 mmol/L
- Vitamin D (25-hydroxyvitamin D): Adequate if >50 nmol/L
- PTH: Refer to nephrologist if persistently elevated and rising above lab reference range
📉 Pathophysiology in CKD
As kidney function declines:
- ↓ Renal phosphate clearance → ↑ serum phosphate
- ↓ Calcitriol synthesis (kidney-dependent) → ↓ calcium absorption
- ↓ Calcium from reduced GI absorption (due to ↓ calcitriol)
- ↓ Vitamin D → ↓ calcium absorption and bone mineralisation
Combined effects:
- ↑ PTH secretion (secondary hyperparathyroidism)
- ↑ Bone resorption → ↑ fracture risk
- ↑ Cardiovascular mortality (likely via vascular calcification)
💊 Management Strategies
1. Vitamin D Replacement
- Cholecalciferol (Vitamin D₃):
- Converted to 25(OH)D in liver
- Renal function needed to convert to calcitriol
- Use for vitamin D deficiency even in advanced CKD
- Calcitriol:
- Used when eGFR is low
- Directly suppresses PTH
- Preferred in advanced CKD for secondary hyperparathyroidism
2. Phosphate Management
- Dietary phosphate restriction
- Phosphate binders:
- Calcium-based (e.g., calcium carbonate)
- Non-calcium binders (e.g., Sevelamer, Lanthanum) – preferred in dialysis patients or where calcium overload is a concern
3. Calcium Management
- If PO₄ is controlled, calcium usually stays in range
- If Ca low with normal PO₄, consider Vitamin D supplementation
- Avoid calcium excess – risk of vascular calcification
Shared Decision Making (SDM)
Definition:
- A collaborative process where clinicians and patients make informed health decisions together.
- Involves:
- Discussing available options, their benefits and harms
- Exploring the patient’s values, preferences, and circumstances
- Is an ongoing process, not a one-off conversation
- Applicable to decisions about screening, investigations, and treatments
Benefits:
- Acknowledges patient values
- Enhances engagement and empowerment
- Improves knowledge and understanding
- Supports evidence-based care
Key Questions to Facilitate SDM:
- What will happen if we watch and wait?
- What are your test or treatment options?
- What are the benefits and harms of these options?
- How do the benefits and harms weigh up for you?
- Do you have enough information to make a choice?
Decision Support Tools:
- Not mandatory, but increasingly used to aid SDM
📝 Advance Care Planning (ACP)
Definition:
- Planning for end-of-life care and preferences, separate from dialysis decisions
- Can occur while patients are still on active treatment
When to Initiate ACP:
- All competent patients ≥65 years
- Competent patients of any age who have:
- Reduced life expectancy due to medical conditions
- Poor functional status
- Chronic malnutrition
- Poor quality of life
🏥 Multidisciplinary Team (MDT) Care in CKD
Objectives of MDT Care:
- Provide diagnosis-based therapy
- Slow CKD progression
- Manage co-morbidities (e.g. diabetes, HTN, lipids)
- Prevent/manage cardiovascular disease
- Manage CKD-specific complications:
- Anaemia
- Renal bone disease
- Fluid/electrolyte/acid-base disorders
- Malnutrition
- Plan for renal replacement therapy (RRT)
- Dialysis modality, access, transplant preparation
- Offer conservative and palliative care
Whole-of-Practice Approach to CKD
- Collaborative care involving GP, practice nurses, admin staff.
- Appoint a clinical lead for CKD.
- Importance of correct CKD coding, clinical governance, and e-health systems.
- MBS item numbers can support care:
- Chronic disease management plans (721, 723)
- GP Management Plans
- Team Care Arrangements
- Health assessments
- Nurse and allied health visits
| Team Member | Roles |
|---|---|
| GP | – Ongoing therapeutic relationship – Care coordination – Advocacy for patient goals |
| Nephrologist | – Specialist renal care – RRT planning and complication management |
| Endocrinologist/Diabetologist | – Optimise glycaemic control in diabetic CKD |
| Vascular/Transplant Surgeon | – Create dialysis access – Perform transplant assessment and surgery |
| Practice Nurse / Nurse Practitioner | – Manage CKD to ESKD – Case management and continuity of care |
| Renal Nurse | – Educate on dialysis – Monitor patient condition and provide support |
| Dietitian | – Conduct nutritional assessments – Provide dietary advice – Assist with dialysis timing |
| Pharmacist | – Review medications (especially elderly) – Adjust doses for low eGFR – Prevent polypharmacy |
| – Conduct HMRs and RMMRs | |
| Physiotherapist | – Maintain mobility – Prescribe tailored exercise |
| Mental Health Professionals | – Support psychological wellbeing and adjustment |
| Community Health Professionals | – Provide home care and social support services |
| Patient Educator | – Deliver group and 1:1 education (diet, anaemia, access) – Promote self-management skills |
| Family / Lay Carers | – Provide emotional and practical support |
| Social Worker | – Address financial/insurance/travel issues – Assist in system navigation |
| Aboriginal Health Worker | – Provide cultural support for Indigenous patients/families – Collaborate with social workers |
Culturally Safe CKD Care for First Nations Australians
- Care should be culturally safe and community-inclusive.
- Involve family, community, Aboriginal Health Workers/Practitioners, and interpreters.
- Refer to:
- CARI Guidelines on cultural safety
- Clinical Yarning program (WA Centre for Rural Health)
- HealthInfoNet and NACCHO
Renal Replacement Therapy (RRT) Options
🟩 1. Transplant
Types:
- Living donor
- Deceased donor (may wait 3–7 years)
Involves:
- Major surgery
- Lifetime immunosuppression
- Requires a compatible donor
Lifestyle Impact / Outcomes:
- Best option for quality of life
- Freedom to work and travel once stable
- Requires maintenance of a healthy diet, but few restrictions
- Good survival rates
- Increased risk of infection and malignancy due to immunosuppression
—————————————————–
🟨 2. Home Peritoneal Dialysis (PD)
➤ a. Continuous Ambulatory Peritoneal Dialysis (CAPD)
Involves:
- Manual exchange of four daytime bags
Lifestyle Impact / Outcomes:
- Requires PD catheter
- Simple, gentle, portable dialysis option
- ~1 week training required
- Freedom to work and travel
- Good quality of life
- Treatment longevity: 2–5 years
➤ b. Automated Peritoneal Dialysis (APD)
Involves:
- Machine-managed overnight exchanges
Lifestyle Impact / Outcomes:
- Same as CAPD but:
- No need to manually change bags during the day
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🟦 3. Home Haemodialysis
Types:
- Daytime: 3–5 sessions/week, each 4–6 hrs
- Night-time: 3–5 nights/week, each 8 hrs
Involves:
- Blood cleaned via artificial filter
- Requires surgical fistula (3+ months prior to use)
- ~3 months training required
Lifestyle Impact / Outcomes:
- Allows flexible routines
- Night dialysis offers better health outcomes
- More frequent/longer dialysis associated with:
- Improved blood pressure
- Better phosphate control
- Improved energy levels
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🟥 4. Centre-Based Haemodialysis
Types:
- Delivered in hospital or satellite dialysis centres
- Typically 3 sessions per week, each lasting 4–6 hours
- Some clinics offer overnight dialysis
Involves:
- Similar process to home haemodialysis (blood filtered through an artificial filter)
- Managed entirely by staff – no patient training required
Lifestyle Impact / Outcomes:
- Requires transport to and from the centre
- Imposes a strict routine and strict dietary restrictions
- Higher infection risk due to frequent vascular access
- Suitable for patients unable or unwilling to manage home therapies
—————————————————–
🟫 5. Non-Dialysis Supportive Care (Conservative Management)
Types:
- No dialysis or transplant
- Managed in community settings
- Supported by palliative care teams
Involves:
- Medication and dietary control
- Advance care planning
- Focus on symptom relief, quality of life, and holistic care
Lifestyle Impact / Outcomes:
- Reduced life expectancy compared to dialysis or transplant in most people
- May be equally appropriate for elderly or multimorbid patients
- Especially when dialysis provides limited benefit or adds burden
- Focus on comfort, dignity, and patient goals