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Chronic kidney disease — Australian GP reference
A structured reference for detecting and managing chronic kidney disease in Australian general practice. Interactive KHA colour-coded clinical action plan (eGFR × albuminuria), BP targets, drug considerations, when to refer. Source: Kidney Health Australia CKD Management in Primary Care, 4th edition (2020) — RACGP-endorsed.
Johnson DW, Atai E, Chan M, et al. KHA-CARI guideline: Early chronic kidney disease: detection, prevention and management. Nephrology 2013;18:340–50. Foundation of the colour-coded action plan.
Confirm current PBS criteria for SGLT2i in CKD and finerenone at pbs.gov.au before prescribing.
Reference for registered medical professionals. Not prescribing advice. CKD management requires individualised judgement against patient comorbidities, BP, kidney trajectory, and current TGA/PBS criteria.
Tier 2 — use clinical judgement. CKD management involves individualisation against BP, albuminuria, comorbidities, life expectancy, and patient preference. This page is a structured reference, not a prescribing protocol. Always confirm current TGA Product Information and PBS criteria. Verified June 2026.
Scale of the problem in Australia: CKD contributes to ~20,000 deaths/year (AIHW 2024). 3 in 4 Australians are at increased risk. Twice as common in First Nations Australians. Only 7.4% of adults with biomarker-positive CKD self-report the diagnosis — CKD is chronically under-diagnosed in primary care. The Kidney Health Check (BP + ACR + eGFR) targets at-risk groups.
KHA clinical action plan — colour-coded classifier
Enter eGFR and urine ACR. The KHA colour-coded zone determines monitoring frequency, BP target, and referral threshold. Source: KHA-CARI guideline, KHA 2020 handbook Table 1.
eGFR uses CKD-EPI (Australian standard); ACR is the spot urine albumin-to-creatinine ratio. For DOAC dose decisions use Cockcroft-Gault (CrCl) — not eGFR.
Kidney Health Check — targeted screening
KHA recommends Kidney Health Check (KHC) every 1–2 years in patients with one or more risk factors. The check is just three components: BP, urine ACR (spot), eGFR (serum creatinine).
Risk factors triggering KHC:
Diabetes (T1 or T2)
Hypertension (treated or untreated)
Established CVD (IHD, stroke, PAD, HF)
Family history of kidney failure
Age ≥ 60 years
First Nations Australian ≥ 18 (annual KHC recommended)
Obesity (BMI ≥ 30)
Smoking (current)
History of AKI
Recurrent UTIs, kidney stones, single kidney
CKD diagnosis requires two abnormal results ≥ 3 months apart (abnormal eGFR, abnormal ACR, or structural abnormality on imaging). Single-result abnormality is not CKD — repeat before labelling.
Management priorities (all CKD stages)
1. Blood pressure control
Target < 140/90 in CKD without albuminuria; < 130/80 if ACR > 3 mg/mmol. ACEi or ARB first-line in albuminuric CKD (any stage) — titrate to maximum tolerated dose. Expect a small creatinine bump (up to 30%) on initiation; continue unless rise > 30% or K⁺ > 5.5. Don't combine ACEi + ARB (ONTARGET).
2. SGLT2 inhibitor (cardio-renal protection)
Dapagliflozin 10 mg daily or empagliflozin 10 mg daily — PBS-listed for diabetic kidney disease and (since 2023) for non-diabetic CKD with proteinuria. Indication: eGFR ≥ 25 with ACR ≥ 22.6 mg/mmol (approximate threshold; check current PBS criteria). DAPA-CKD + EMPA-KIDNEY trials. Continue down to dialysis in most cases. Withhold during acute illness/dehydration (sick-day rules).
3. Albuminuria reduction
Stepwise approach (KHA 2020): RAAS inhibition first → SGLT2i if eligible → consider non-steroidal MRA (finerenone) if persistent albuminuria in T2DM despite max RAAS + SGLT2i (FIDELIO-DKD, FIGARO-DKD). Aim for ACR reduction > 30%.
4. Cardiovascular risk management
CKD multiplies CVD risk substantially. Use the updated Australian CVD risk calculator with the CKD modifier (KHA 2020 + AusCVDR 2023). Statin (moderate-intensity) for primary prevention in any CKD with another CV risk factor and age > 50. CKD itself is a high-risk category. Optimise BMI, smoking, exercise.
5. Glycaemic control (if diabetic)
Individualised HbA1c target (typically 53–58 mmol/mol; less strict if frail). Metformin: reduce dose at eGFR < 45, cease at < 30. SGLT2i and GLP-1 agonists preferred for renal/CV benefit. Avoid sulphonylureas if hypoglycaemia risk. Insulin doses often reduce in advanced CKD.
6. Lifestyle and nutrition
Sodium < 5 g/day (< 100 mmol Na⁺/day). Adequate hydration (water to thirst). Protein 0.8–1.0 g/kg/day in earlier CKD; consider dietitian for advanced CKD. Physical activity 150–300 min moderate / week. Weight optimisation. Smoking cessation. Alcohol limitation.
Drug considerations in CKD
Drug / class
CKD consideration
Metformin
Reduce dose at eGFR < 45 (max 1g/day); cease at eGFR < 30. Withhold during acute illness.
NSAIDs
Avoid in CKD where possible — especially with ACEi/ARB/diuretic ("triple whammy"). Risk: AKI. Topical preferable; paracetamol or short-course tramadol as alternatives.
DOACs (apixaban, rivaroxaban, dabigatran)
Use CrCl (Cockcroft-Gault), not eGFR. See AF management page for dose criteria. Dabigatran avoid < 30, apixaban caution < 25.
Allopurinol
Start low (50–100 mg) and uptitrate slowly to urate target. Renal dose adjustment needed.
Gabapentinoids (gabapentin, pregabalin)
Dose-adjust by CrCl. Sedation/falls risk in elderly with CKD.
Opioids
Codeine, morphine, tramadol metabolites accumulate — oxycodone or buprenorphine preferred in CKD. See oMEDD calculator.
Antibiotics
Renal dose adjustment for trimethoprim, nitrofurantoin (avoid CrCl < 30), aminoglycosides, fluoroquinolones, vancomycin. Cefalexin generally safe.
Iodinated contrast
Risk of contrast-associated AKI. Hydrate. Withhold metformin & SGLT2i around contrast. Liaise with radiology if eGFR < 30.
PBS S100 phosphate binders, ESAs
Generally specialist-initiated.
Sick-day rules
When patients with CKD are unwell with vomiting, diarrhoea, sepsis, or significant dehydration, temporarily withhold:
Resume when eating and drinking normally for 24–48 hours
Provide a written sick-day plan; document on first review when starting any of these in CKD
First Nations Australians
CKD is twice as common in First Nations Australians, presents earlier, progresses faster. KHA recommends annual KHC from age 18 (rather than 60+ for non-Indigenous). MBS items 715 (health assessment) covers this. Culturally safe care principles: shared decision-making with family/community; understanding country and connection in care planning; working with ACCHOs where available. KHA has dedicated First Nations resources.
When to refer to nephrology
Urgent referral (within days):
AKI — rise in creatinine ≥ 26 µmol/L in 48h, or ≥ 1.5× baseline in 7 days
Persistent unexplained haematuria with proteinuria
Recurrent kidney stones or single kidney
Monitoring intervals (KHA 2020)
Frequency is determined by the colour zone above. In general:
Green zone: annual eGFR, ACR, BP
Yellow zone: every 6–12 months
Orange zone: every 3–6 months
Red zone: every 1–3 months + nephrology co-management
Add: 6-monthly U&E, FBC, lipids, calcium/phosphate, PTH, vitamin D in moderate–advanced CKD
Annual: bicarbonate, urate; ferritin/iron studies if anaemic
MBS billing context
Standard GP items (23, 36, 44). Kidney Health Check fits within standard consult — no separate item. CKD qualifies for CDM: GPMP (item 965) and TCA (item 967). See CDM changes guide and care plan tips. Health Assessment item 715 for First Nations Australians (annual). Nephrology referrals: standard specialist letter.