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Chronic kidney disease management − primary care

A-Z Frankston-Mornington Peninsula local pathways > Chronic Kidney Disease > Chronic kidney disease

Care map Information resources Aboriginal and Torres
information for patients and carers Strait Islanders

DEFINITION OF CKD
eGFR<60 mL/min/1.73
m2 and/or evidence of
kidney damage for at
least 3 months

Classify stage
according to eGFR
and structural renal
disease

Management

Low risk Moderate risk High risk

eGFR ≥60 mL/ eGFR 30-59 mL/ Macroalbuminuria
min/ 1.73m2 with min/1.73m2 with irrespective of eGFR
microalbuminuria microalbuminuria OR
OR OR eGFR <30 mL/
eGFR 45-59 mL/ eGFR 30-44 mL/ min /1.73m2
min/ 1.73m2 with min/1.73m2 with irrespective of
normoalbuminuria normoalbuminuria albuminuria

Goals of management Goals of management Goals of management

REFERRAL
Monitoring Monitoring Nephrologist

Absolute Cardiovascular risk - Monitoring
Cardiovascular risk high
assessment tool
Cardiovascular risk -
high
Interventions

Preemptive
Lipid lowering and Common drugs to Transplantation
Blood pressure Anaemia management
reduction glycaemic control avoid

Renal management
BP lowering agents towards the end of life

Advanced Care
REFERRAL Planning
Nephrologists

Published: 01-Jul-2016 Valid until: 17-Nov-2017 Printed on: 20-Dec-2017 © Map of Medicine Ltd

This care map was published by Frankston MorningtonPsula. A printed version of this document is not controlled so may not be up-to-date
with the latest clinical information.
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Chronic kidney disease management − primary care
A-Z Frankston-Mornington Peninsula local pathways > Chronic Kidney Disease > Chronic kidney disease

1 Aboriginal and Torres Strait Islanders
Quick info:
Aboriginal and Torres Strait Islander peoples [1]
Age-standardised incidence of end stage kidney disease is significantly higher in Aboriginal and Torres Strait Islander peoples
compared with non Aboriginal and Torres Strait Islander peoples.
Recommendations for CKD detection in Aboriginal and Torres Strait Islander peoples:
Indication for testing:
1. People 18-29 years without any CKD risk factors:
• Assess for CKD risk factors(overweight and obesity, diabetes, elevated blood pressure, smoking, and family history of kidney
disease
• As part of annual health assessment
2. People 18-29 years with one of the following CKD risk factors:
• Family history of CKD or
• premature CVD
• Overweight/obesity
• Smoking
• Diabetes
• Elevated blood pressure
AND all people ≥30 years:
Recommended tests
• Urine ACR, eGFR,
• blood pressure
Frequency of testing:
• Every two years (or more frequently if CVD risk is elevated)
Note. If urine ACR positive arrange 2 further tests over 3 months (preferably first morning void).
If eGFR < 60mL/min/1.73m2 repeat within 14 days.
Source: National Guide to a preventive health assessment in Aboriginal and Torres Strait Islander peoples
(NACCHO) (2012, in press).
Benefits of identifying Aboriginal and Torres Strait Islander peoples:
• Clinician awareness of increased risk of CKD and cardiovascular disease and importance of screening other family members
for CKD.
• Individuals able to access annual health check (Medicare item 715).
• Individuals eligible for Aboriginal and Torres Strait Islander peoples-specific pharmaceutical benefits.
• Individuals are eligible for “Close the Gap” PBS co-payments.
• The Aboriginal and Torres Strait Islander community becomes engaged with the health care system.
For further detailed information refer to the NACCHO National Guide to a preventive health assessment in Aboriginal and Torres
Strait Islander peoples (www.naccho.org.au)
References
[1] Chronic Kidney Disease (CKD) Management in General Practice (2nd edition). Kidney Health Australia, Melbourne, 2012.

2 Information resources for patients and carers
Quick info:
Fact sheets from Kidney Health Australia

3 Care map information
Quick info:
What is Chronic Kidney Disease (CKD)? [1]

Published: 01-Jul-2016 Valid until: 17-Nov-2017 Printed on: 20-Dec-2017 © Map of Medicine Ltd

This care map was published by Frankston MorningtonPsula. A printed version of this document is not controlled so may not be up-to-date
with the latest clinical information.
Page 2 of 13
Chronic kidney disease management − primary care
A-Z Frankston-Mornington Peninsula local pathways > Chronic Kidney Disease > Chronic kidney disease

Chronic kidney disease (CKD) is diagnosed as:
• an estimated or measured glomerular filtration rate (GFR) < 60 mL/min/1.73m2that is present for ≥3 months with or without
evidence of kidney damage
or
• evidence of kidney damage with or without decreased GFR that is present for ≥3 months as evidenced by the following,
irrespective of the underlying cause:
- albuminuria
- haematuria after exclusion of urological causes
- structural abnormalities (e.g., on kidney imaging tests)
- pathological abnormalities (e.g., renal biopsy)

References
[1] Chronic Kidney Disease (CKD) Management in General Practice (2nd edition). Kidney Health Australia,
Melbourne, 2012.

5 Classify stage according to eGFR and structural renal disease
Quick info:
Staging of CKD [1]
Combine Kidney Function Stage (stage 1-5) with description of kidney damage (albuminuria) and clinical diagnosis to specify CKD
fully (e.g., Stage 2 CKD with microalbuminuria, secondary to diabetic kidney disease).
For people with CKD, the combination of low GFR and albuminuria places them at greater risk of CKD and CVD progression at all
ages
than those with just one of low GFR or albuminuria.

See the Kidney Health Australia colour coded staging diagram for more information.

Reference
[1] Chronic Kidney Disease (CKD) Management in General Practice (2nd edition). Kidney Health Australia,Melbourne, 2012.

12 Macroalbuminuria irrespective of eGFR OR eGFR <30 mL/min /1.73m2 irrespective of
albuminuria
Quick info:
Macroalbuminuria
• Urine ACR: Male > 25 mg/mmol; Female > 35 mg/mmol
• 24h urine albumin: > 300 mg/day

Presents as frothy urine

13 Goals of management
Quick info:
Goals of management [1]
• appropriate referral to a Nephrologist
2
• prepare for dialysis or preemptive transplant if eGFR <30 mL/min/1.73m
• discuss advanced care directive
• reduce progression of kidney disease

Published: 01-Jul-2016 Valid until: 17-Nov-2017 Printed on: 20-Dec-2017 © Map of Medicine Ltd

This care map was published by Frankston MorningtonPsula. A printed version of this document is not controlled so may not be up-to-date
with the latest clinical information.
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Chronic kidney disease management − primary care
A-Z Frankston-Mornington Peninsula local pathways > Chronic Kidney Disease > Chronic kidney disease

• reduce CVD risk
• early detection and management of complications
• avoidance of nephrotoxic medications
• adjustment of medication doses to levels appropriate for kidney function
• multidisciplinary team involvement

References
[1] Chronic Kidney Disease (CKD) Management in General Practice (2nd edition). Kidney Health Australia,Melbourne, 2012.

14 Goals of management
Quick info:
Goals of management
• establish diagnosis of kidney disease and exclude treatable kidney disease
• assessment and management of cardiovascular risk
• reduce rate of CKD progression
• consider earlier referral to nephrologist for younger people or people with significant decrease in renal function over 6 weeks

References
[1] Chronic Kidney Disease (CKD) Management in General Practice (2nd edition). Kidney Health Australia,Melbourne, 2012.

15 Goals of management
Quick info:
Goals of management
• investigations to exclude treatable disease
• reduce progression of kidney disease
• reduce CVD risk
• early detection and management of complications
• avoidance of nephrotoxic medications or volume depletion
• adjustment of medication doses to levels appropriate for kidney function
• consider earlier referral to nephrologist for younger people or people with significant decrease in renal function over 6 weeks
• consider discussing advanced care directive

References
[1] Chronic Kidney Disease (CKD) Management in General Practice (2nd edition). Kidney Health Australia,Melbourne, 2012.

16 REFERRAL Nephrologist
Quick info:
Referral to a Nephrologist
Everyone in this category should be referred to a nephrologist (unless limited life expectancy for other reasons)
• The KHA-CARI guidelines recommend that individuals should be referred to a Nephrologist at least 12 months prior to the
2
anticipated commencement of dialysis and/or kidney transplantation (i.e. referral when eGFR <30 mL/min/1.73m

Tests to accompany referral:
• U&E / LFT
• Fasting glucose/lipids

Published: 01-Jul-2016 Valid until: 17-Nov-2017 Printed on: 20-Dec-2017 © Map of Medicine Ltd

This care map was published by Frankston MorningtonPsula. A printed version of this document is not controlled so may not be up-to-date
with the latest clinical information.
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Chronic kidney disease management − primary care
A-Z Frankston-Mornington Peninsula local pathways > Chronic Kidney Disease > Chronic kidney disease

• Ca
• Po4
• ESR
• CRP
• Uric acid
• Full blood count
• PTH
• vit D
• Iron studies
• Renal ultrasound
• 24 hour urine protein and sodium excretion (if macroalbuminuria)

Peninsula Health
Frankston Hospital CKD clinic
Ph: (03) 9784 7243
Fax: (03) 9784 7289
The Department of Nephrology provides inpatient care, acute dialysis and consultation for all patients admitted to Frankston Hospital
with kidney problems.
In addition, the department provides a range of outpatient clinics for chronic kidney disease, haemodialysis, peritoneal dialysis and
transplant patients.

Private nephrologists
Nephrologist listings from National Health Service Directory

Peninsula Renal Services
17 Hastings Rd, Frankston
Phone: 9769 6307
Fax: (03) 9769 6303
Consultants:
• Dr Robert Flanc
• Dr Vinod Venkataraman

Peninsula Specialists Clinc
118 Williams St, Frankston
Mob 0439 228 338
Ph 9783 2009, Fax 9783 8758
• Dr Kim Wong

Peninsula Private Hospital Consulating Suites
525 McClelland Dve
Ph 9770 9772 Fax 9770 9774
• Dr Alinda Chiu

Details of relevant service providers are listed as a service for clinicians. Listing in this pathway is not an endorsement of the
provider. If any relevant providers have been missed or if information is incorrect, please use the feedback button on the bottom right
of the page to alert us.

References
[1] Chronic Kidney Disease (CKD) Management in General Practice (2nd edition). Kidney Health Australia,Melbourne, 2012.

Published: 01-Jul-2016 Valid until: 17-Nov-2017 Printed on: 20-Dec-2017 © Map of Medicine Ltd

This care map was published by Frankston MorningtonPsula. A printed version of this document is not controlled so may not be up-to-date
with the latest clinical information.
Page 5 of 13
Chronic kidney disease management − primary care
A-Z Frankston-Mornington Peninsula local pathways > Chronic Kidney Disease > Chronic kidney disease

17 Monitoring
Quick info:
Monitoring
• 6-12 monthly clinical review
• clinical assessment
• blood pressure
• weight
laboratory assessment
• urine ACR
• biochemical profile including urea, creatinine and electrolytes
• eGFR
• HbA1c (for people with diabetes)
• fasting lipids

References
[1] Chronic Kidney Disease (CKD) Management in General Practice (2nd edition). Kidney Health Australia,Melbourne, 2012.

18 Monitoring
Quick info:
Monitoring
• 3-6 monthly clinical review
• clinical assessment
• blood pressure
• weight
• laboratory assessment
• urine ACR
• biochemical profile including urea, creatinine and electrolytes
• eGFR
• HbA1c (for people with diabetes)
• fasting lipids
• full blood count
• calcium and phosphate
2
• parathyroid hormone (6-12 monthly if eGFR < 45 mL/min/1.73m )

References
[1] Chronic Kidney Disease (CKD) Management in General Practice (2nd edition). Kidney Health Australia,Melbourne, 2012.

19 Absolute Cardiovascular risk assessment tool
Quick info:
Absolute cardiovascular risk assessment
• People with CKD have a 20 times greater risk of dying from cardiovascular events than requiring dialysis or transplantation
• The presence of CKD is one of the most potent known risk factors for CVD.
• Perform absolute cardiovascular risk assessment using the Australian CVD tool for all adults aged 45-74 years (35 years and
above for Aboriginal and Torres Strait Islander peoples) without existing CVD and without a clinically determined risk factor
• Provide lifestyle and pharmacological management strategies (if indicated) based on the patient’s risk level and clinical
judgement

Published: 01-Jul-2016 Valid until: 17-Nov-2017 Printed on: 20-Dec-2017 © Map of Medicine Ltd

This care map was published by Frankston MorningtonPsula. A printed version of this document is not controlled so may not be up-to-date
with the latest clinical information.
Page 6 of 13
Chronic kidney disease management − primary care
A-Z Frankston-Mornington Peninsula local pathways > Chronic Kidney Disease > Chronic kidney disease

Australian absolute cardiovascular diesase risk calculator
Australian cardiovascular risk charts
Medical Director Cardiovascular Risk Calculator, under Tools>Tool Box
Best Practice Cardiovascular risk under Clinical

References
[1] Chronic Kidney Disease (CKD) Management in General Practice (2nd edition). Kidney Health Australia,Melbourne, 2012.

20 Cardiovascular risk - high
Quick info:
Cardiovascular risk
• People with CKD have a 20 times greater risk of dying from cardiovascular events than requiring dialysis or transplantation
• People with moderate or severe CKD (defined as persistently having a urine ACR >25 mg/mmol (males) or >35 mg/mmol
2
(females) or eGFR <45mL/min/1.73m are considered to be at the highest risk of a cardiovascular event and do not need to be
assessed by the cardiovascular risk tool.
• For these groups, identifying all cardiovascular risk factors present will enable intensive management by lifestyle interventions
(for all patients) and pharmacological interventions (where indicated).
• See also lifestyle modification, blood pressure reduction, lipid lowering treatments, and glycaemic control
References
[1] Chronic Kidney Disease (CKD) Management in General Practice (2nd edition). Kidney Health Australia,Melbourne, 2012.

21 Monitoring
Quick info:
Monitoring
• 1-3 monthly clinical review
• clinical assessment
• blood pressure
• weight
• oedema
• laboratory assessment
• urine ACR
• biochemical profile including urea, creatinine and electrolytes
• eGFR
• HbA1c (for people with diabetes)
• fasting lipids
• full blood count (if anaemic see Page 30)
• calcium and phosphate
• parathyroid hormone (6-12 monthly if eGFR < 45 mL/min/1.73m2

References
[1] Chronic Kidney Disease (CKD) Management in General Practice (2nd edition). Kidney Health Australia,Melbourne, 2012.

22 Cardiovascular risk - high
Quick info:
Cardiovascular risk

Published: 01-Jul-2016 Valid until: 17-Nov-2017 Printed on: 20-Dec-2017 © Map of Medicine Ltd

This care map was published by Frankston MorningtonPsula. A printed version of this document is not controlled so may not be up-to-date
with the latest clinical information.
Page 7 of 13
Chronic kidney disease management − primary care
A-Z Frankston-Mornington Peninsula local pathways > Chronic Kidney Disease > Chronic kidney disease

• People with CKD have a 20 times greater risk of dying from cardiovascular events than requiring dialysis or transplantation
• People with moderate or severe CKD (defined as persistently having a urine ACR >25 mg/mmol (males) or >35 mg/mmol
2
(females) or eGFR <45mL/min/1.73m are considered to be at the highest risk of a cardiovascular event and do not need to be
assessed by the cardiovascular risk tool.
• For these groups, identifying all cardiovascular risk factors present will enable intensive management by lifestyle interventions
(for all patients) and pharmacological interventions (where indicated).
References
[1] Chronic Kidney Disease (CKD) Management in General Practice (2nd edition). Kidney Health Australia,Melbourne, 2012.

24 Preemptive Transplantation
Quick info:
Preemptive Transplantation
Preemptive transplantation means receiving a kidney transplant from a live donor prior to initiation of dialysis. Preemptive
transplantation is associated with:
• reduced risk of death
• longevity of functioning of the transplanted kidney
• psychosocial benefits
• economic benefits
A preemptive transplant can only be performed when the individual’s kidney function has deteriorated to a level that justifies the risks
2
and complications of transplantation (eGFR usually 8-15 mL/min/1.73m ), but before dialysis is needed.

References
[1] Chronic Kidney Disease (CKD) Management in General Practice (2nd edition). Kidney Health Australia,Melbourne, 2012.

25 Common drugs to avoid
Quick info:
It is important to review renally excreted medications, as well as avoid nephrotoxic
medications in people with CKD.
Consider a Home Medicine Review.

Commonly prescribed drugs that may need to be reduced in dose or ceased in CKD
• Antivirals
• Benzodiazepines
• Colchicine
• Dabigatran
• Digoxin
• Exenatide
• Fenofibrate
• Gabapentin
• Insulin
• Lithium
• Metformin*
• Opioid analgesics
• Saxagliptin
• Sitagliptin
• Sotalol
• Spironolactone

Published: 01-Jul-2016 Valid until: 17-Nov-2017 Printed on: 20-Dec-2017 © Map of Medicine Ltd

This care map was published by Frankston MorningtonPsula. A printed version of this document is not controlled so may not be up-to-date
with the latest clinical information.
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Chronic kidney disease management − primary care
A-Z Frankston-Mornington Peninsula local pathways > Chronic Kidney Disease > Chronic kidney disease

• Sulphonylureas (all)
• Vildagliptin

2
*use with caution if GFR 30-60 mL/min/1.73m
2
; not recommended if GFR < 30 mL/min/1.73m

Commonly prescribed drugs that can adversely affect kidney function in CKD
• NSAIDs and COX-2 inhibitors
• Beware the ‘triple whammy’ of NSAID/COX-2 inhibitor, ACE inhibitor and diuretic
• (low dose aspirin is okay)
• Radiographic contrast agents
• Aminoglycosides
• Lithium
• Calcineurin inhibitors

Over the counter medications/supplements
E.g Vitamin C, precribed herbs should be specifically asked about
Dosage reduction or cessation of renally excreted medications is generally required
2
once the GFR falls below 60 mL/min/1.73m
References
[1] Chronic Kidney Disease (CKD) Management in General Practice (2nd edition). Kidney Health Australia,Melbourne, 2012.

26 Lipid lowering and glycaemic control
Quick info:
Lipid-lowering treatments
Lipid-lowering treatment should be considered where appropriate for CVD risk reduction.
See the PBS guidelines for criteria to determine patient eligibility for subsidisation.

Glycaemic control
For people with diabetes, blood glucose control significantly reduces the risk of developing CKD, and in those with CKD reduces the
rate of progression.

References
[1] Chronic Kidney Disease (CKD) Management in General Practice (2nd edition). Kidney Health Australia,Melbourne, 2012.

27 Blood pressure reduction
Quick info:
BP target for reduction
<140/90 for CKD with normoalbuminuria
< 130/80 for CKD with albuminuria
CKD can cause and aggravate hypertension, and hypertension can contribute to the progression of CKD.
• Reducing blood pressure to below threshold levels is one of the most important goals in management of CKD
• ACE inhibitor or ARB is recommended as first line therapy.
• Angiotensin converting enzyme inhibitor (ACEI) and angiotensin II receptor blocker (ARB) therapy is associated with a
reduction in proteinuria and slowing of the rate of progression of kidney failure.
• Combined therapy of ACE inhibitor and ARB is not recommended.
• Maximal tolerated doses of ACE inhibitor or ARB is recommended.

Published: 01-Jul-2016 Valid until: 17-Nov-2017 Printed on: 20-Dec-2017 © Map of Medicine Ltd

This care map was published by Frankston MorningtonPsula. A printed version of this document is not controlled so may not be up-to-date
with the latest clinical information.
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Chronic kidney disease management − primary care
A-Z Frankston-Mornington Peninsula local pathways > Chronic Kidney Disease > Chronic kidney disease

• Hypertension may be difficult to control and multiple (3 - 4) medications are frequently required
ACE inhibitors and ARBs can cause a reversible reduction in GFR when treatment is initiated. If the reduction is less than 25% and
stabilises within two months of starting therapy, the ACE inhibitor or ARB should be continued.
If the reduction in GFR exceeds 25% below the baseline value, the ACE inhibitor or ARB should be ceased and consideration given
to referral to a Nephrologist for bilateral renal artery stenosis

References
[1] Chronic Kidney Disease (CKD) Management in General Practice (2nd edition). Kidney Health Australia,Melbourne, 2012.

28 Anaemia management
Quick info:
Anaemia of CKD is related to both:
• reduced erythropoietin production by the kidney
• resistance to the action of erythropoietin
2.
Anaemia related to CKD usually occurs at GFRs of <60 mL/min/1.73m
The prevalence of anaemia increases markedly with decreasing GFR.

Management
• Other forms of anaemia should be considered and excluded.
• B12 and folate levels should be checked and corrected if deficient.
• Iron deficiency is a common cause of anaemia in people with CKD.
• If iron deficiency is identified any other cause should be excluded (e.g., blood loss).
• In people with CKD treated with erythropoiesis stimulating agents (ESA or EPO) iron supplementation is typically required. This
can be given either as oral iron or not infrequently as intravenous supplementation (more information on IV supplementation
such as Ferinject is available from NPS). Intramuscular iron is not recommended.

References
[1] Chronic Kidney Disease (CKD) Management in General Practice (2nd edition). Kidney Health Australia,Melbourne, 2012.

29 Renal management towards the end of life
Quick info:
2
When eGFR<30mL/min/1.73m it may be necessary to consider end of life decisions including advanced care directives to outline
wishes for future health and personal care, including non-dialysis treatment (no dialysis or transplantation), and palliative care
arrangements[1].

Other indicators [2]:
• patients choosing not to have dialysis, discontinuing dialysis, or not opting for dialysis if their transplant has failed
• patients with difficult physical symptoms or psychological symptoms despite optimal tolerated renal replacement therapy
• symptomatic renal failure − nausea and vomiting, anorexia, pruritus, reduced functional status, intractable fluid overload
• increasingly severe symptoms from co-morbid conditions requiring more complex management or which are difficult to treat

References:
1. Kidney Health Australia. Chronic Kidney Disease Management in General Practice. 2nd Edition. 2012
2.The Gold Standard Framework (GSF). Prognostic Indicator Guidance. Walsall: GSF; 2011.

30 BP lowering agents

Published: 01-Jul-2016 Valid until: 17-Nov-2017 Printed on: 20-Dec-2017 © Map of Medicine Ltd

This care map was published by Frankston MorningtonPsula. A printed version of this document is not controlled so may not be up-to-date
with the latest clinical information.
Page 10 of 13
Chronic kidney disease management − primary care
A-Z Frankston-Mornington Peninsula local pathways > Chronic Kidney Disease > Chronic kidney disease

Quick info:
ACEI and ARB
ACEI or ARB can be safely prescribed in patients with any stage of kidney disease, bearing in mind the following points [1]:
There is a significant risk of hyperkalaemia
• Stop the ACEI or ARB if potassium concentration is more than 6 mmol/L and does not respond to dose reduction, diuretic
therapy and dietary potassium restriction.
In patients with haemodynamically significant renal artery stenosis, ACEI and ARB can cause further impairment of glomerular
perfusion in the affected kidney, and precipitate acute deterioration in kidney function.
When commencing ACEI it is advisable to check renal function in 2 weeks then test monthly tests for 3 months, then test 3-6
monthly (KW).
• Monitor serum levels of creatinine and potassium closely.
• If the acute decrease in estimated glomerular filtration rate (eGFR) is less than 25% below the baseline and stabilises within 2
months of starting therapy, the ACEI or ARB may be continued.
• If the decrease in eGFR is greater than 25% below the baseline, stop the ACEI or ARB and refer the patient for investigation of
possible bilateral renal artery stenosis.
Take particular care in a patient with kidney disease treated with both an ACEI or ARB and a diuretic.
• Do not add a nonsteroidal anti-inflammatory drug (including selective cyclo-oxygenase-2 [COX-2] inhibitors) to this combination
—the 'triple whammy'—as this can cause acute kidney failure.
Most ACEI are renally excreted, and therefore lower doses are likely to be needed to control hypertension. Most ARB are
predominantly excreted by the liver, so no dose adjustment is necessary.
ACEI therapy may interfere with the actions of erythropoietin.

Calcium channel blockers
Calcium channel blockers are effective in BP control in patients with kidney disease, and are effective in slowing progression of
kidney failure.
• Usually added to ACEI or ARB therapy, or used as an alternative to ACEI or ARB in patients who are intolerant of these drugs.
• Use lower doses of lercanidipine in patients with kidney disease, and titrate to effect. Dosage regimens of other calcium
channel blockers are unaffected by kidney disease.

Loop dieuretics
At significantly reduced levels of kidney function (eGFR less than 50 mL/min), loop diuretics are used, because thiazide diuretics are
no longer effective.
The dose should be adjusted according to the level of kidney function, commencing with frusemide 40 mg/day or bumetanide 1
mg/day, increasing gradually to a maximum frusemide dose of 500 mg/day or bumetanide 10 mg/day. High doses carry a risk of
ototoxicity and should only be considered in consultation with a nephrologist.

Beta blockers
Some beta blockers (eg atenolol) are renally excreted, and dosage adjustment may be necessary in kidney disease.
• They can have deleterious effects on lipids and potassium.
• They are associated with erectile dysfunction in some patients, which may limit their use, as the incidence of impotence
increases in kidney failure.

Alpha blockers
Alpha blockers can cause unacceptable orthostatic hypotension on initial dosage and when the dose is increased.
• In the longer term, increasingly higher doses may be needed to achieve the same effect, which limits their usefulness.
However, occasionally they may be useful adjunctive therapy.

Minoxidil
The potent vasodilator minoxidil can be very effective in some patients with kidney disease and severe hypertension, but the
associated sodium retention and tachycardia limit its use.

Reference
1. Cardiovascular [revised 2012]. In: eTG complete [Internet]. Melbourne: Therapeutic Guidelines Limited; 2014 Nov.

Published: 01-Jul-2016 Valid until: 17-Nov-2017 Printed on: 20-Dec-2017 © Map of Medicine Ltd

This care map was published by Frankston MorningtonPsula. A printed version of this document is not controlled so may not be up-to-date
with the latest clinical information.
Page 11 of 13
Chronic kidney disease management − primary care
A-Z Frankston-Mornington Peninsula local pathways > Chronic Kidney Disease > Chronic kidney disease

31 Advanced Care Planning
Quick info:
Advanced Care Directives
2
When eGFR<30mL/min/1.73m it may be necessary to consider end of life decisions including advanced care directives to outline
wishes for future health and personal care, including nondialysis treatment (no dialysis or transplantation), and palliative care
arrangements.

Link to Advance Care Planning page

32 REFERRAL Nephrologists
Quick info:
Referral criteria for nephrologist may include [1]:
• glomerular haematuria with macroalbuminuria
2
• eGFR <30 mL/min/1.73m
• persistent significant albuminuria (UACR ≥30 mg/mmol)
2 2
• consistent decline in eGFR from a baseline of <60 mL/min/1.73m (a decline >5 mL/min/1.73m over a 6-month period which is
confirmed on at least three separate readings)
• CKD and hypertension that is hard to get to target despite at least three antihypertensive agents.

Peninsula Health CKD clinic
Ph 9784 7319
Fax: 9784 7650
Consultant: Dr Kim Wong, Head of Nephrology

Peninsula Health CKD Education Clinic
Fax 9784 8906
Consulatants: Dr Kim Wong, Head of Nephrology, Dr Alinda Chiu

The Department of Nephrology provides acute care to patients admitted with kidney diseases.
The range of services include acute dialysis for stable and unstable ICU/CCU patients, haemodialysis, peritoneal dialysis,
hypertension management, general renal diagnosis and management, urgent and elective kidney biopsies services. The Department
also provides a range of clinics for Haemodialysis, Peritoneal Dialysis, Pre-Dialysis education and end of life care services for patient
with kidney diseases.

Private nephrologists
Nephrologist listings from National Health Service Directory

Peninsula Specialists Clinc
118 Williams St, Frankston
Mob 0439 228 338
Ph 9783 2009, Fax 9783 8758
• Dr Kim Wong

Peninsula Renal Services
17 Hastings Rd, Frankston
Phone: 9769 6307
Fax: (03) 9769 6303
Consultants:

Published: 01-Jul-2016 Valid until: 17-Nov-2017 Printed on: 20-Dec-2017 © Map of Medicine Ltd

This care map was published by Frankston MorningtonPsula. A printed version of this document is not controlled so may not be up-to-date
with the latest clinical information.
Page 12 of 13
Chronic kidney disease management − primary care
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• Dr Robert Flanc
• Dr Vinod Venkataraman

Peninsula Private Hospital Consulting Suites
525 McClelland Dve
Ph 9770 9772 Fax 9770 9774
• Dr Alinda Chiu

Details of relevant service providers are listed as a service for clinicians. Listing in this pathway is not an endorsement of the
provider. If any relevant providers have been missed or if information is incorrect, please use the feedback button on the bottom right
of the page to alert us.

References
[1] Chronic Kidney Disease (CKD) Management in General Practice (2nd edition). Kidney Health Australia,Melbourne, 2012.

Published: 01-Jul-2016 Valid until: 17-Nov-2017 Printed on: 20-Dec-2017 © Map of Medicine Ltd

This care map was published by Frankston MorningtonPsula. A printed version of this document is not controlled so may not be up-to-date
with the latest clinical information.
Page 13 of 13
Chronic Kidney Disease
Medicine/Nephrology

Provenance certificate
Contents

 Overview
 Editorial methodology
 Contributors
 Disclaimers

Overview

This document describes the provenance of the Peninsula Pathways, Chronic Kidney Disease care
map (pathway).

This pathway was last updated in April 2015.

The Peninsula Pathways Program aims to improve the continuity of patient care between primary,
community and hospital care settings in the Frankston-Mornington Peninsula region. Work groups
comprising of experienced health professionals (GPs, specialists, nurses, allied health professionals)
were established to review and localise pathways.

The objective of this pathway is to improve outcomes for patients with chronic kidney disease.

To cite this pathway, use the following format:

Map of Medicine (MoM). Chronic Kidney Disease. Frankston-Mornington Peninsula Medicare Local
View. Melbourne: Map of Medicine; 2015.

Editorial methodology

This pathway is currently the first version localised to Frankston Mornington Peninsula.

This pathway has been developed according to the Map of Medicine editorial methodology, using
the evidence and expert advice of the international heart failure pathway as a starting point. The
content of this care map was further developed with reference to Kidney Health Australia guidelines
and other current evidence-based guidelines and practice-based knowledge provided by local
practitioners with front-line clinical experience (see contributors section of this document).

Contributors

The following were clinical contributors to the Chronic Kidney Disease pathway:

 Dr Kim Wong | Nephrologist, Head of Nephrology, Peninsula Health
 Dr Damian Flanagan | General Practitioner
 Dr Glenn Mathieson | General Practitioner
Chronic Kidney Disease
Medicine/Nephrology

Editor

• Nick Jones | Service Integration Manager, Frankston Mornington Peninsula Medicare Local

The following were contributors through the GP review committee and wider consultation process:

 Dr Jo Newton | GP Liaison, Peninsula Health
 Dr Martin Coffey| General Practitioner
 Dr Peter Meggyesy| General Practitioner
 Dr Emma Donovan| General Practitioner

Conflicts of interest: None declared

Disclaimer

It is not the function of the Pathways Program, Frankston-Mornington Peninsula Medicare Local to
substitute for the role of the clinician, but to support the clinician in enabling access to know-how
and knowledge. Users of the Map of Medicine are therefore urged to use their own professional
judgement to ensure that the patient receives the best possible care. Whilst reasonable efforts have
been made to ensure the accuracy of the information on this online clinical knowledge resource, we
cannot guarantee its correctness and completeness. The information on the Map of Medicine is
subject to change and we cannot guarantee that it is up-to-date