CKD — Practical Care, Dosing & Referral

Annual review, sick-day rules, when to refer

Field: RenalCode: REN-01BUpdated: June 2026Reference: KDIGO 2024 / Kidney Health Australia

Slow the decline: aggressive BP control + RAS blockade + an SGLT2 inhibitor, and refer early for high-risk patients. Most preventable harm comes from NSAIDs and dehydration on top of ACEi/ARB and diuretics — sick-day rules matter as much as the drug choices themselves.

Annual kidney health check

At-risk groups (every 1–2 years): diabetes, hypertension, CVD, age≥60, smoking, family history, Aboriginal or Torres Strait Islander background, obesity.
Three core tests: eGFR + uACR (first-morning sample) + BP — repeat in 3 months if abnormal.
Confirm + monitor: need 2 abnormal results ≥3 months apart; Stage 3b or higher — review 3-monthly with nephrology input.
Vaccination: annual influenza and pneumococcal; COVID and hepatitis B per current schedule if at-risk.

Sick day rules — SADMANS. Temporarily stop during vomiting, diarrhoea, fever or dehydration: Sulfonylureas, ACE inhibitors, Diuretics, Metformin, ARBs, NSAIDs, SGLT2 inhibitors. Resume once eating and drinking normally; check eGFR if illness lasts more than 48 hours. Avoid the "triple whammy" (ACEi/ARB + diuretic + NSAID together) at any time — a major preventable cause of acute kidney injury.

Drug dosing — eGFR bands

Metformin: standard to eGFR 45; max 1g twice daily and monitor at eGFR 30–45; avoid below eGFR 30.
SGLT2 inhibitors: standard dose once eligible; can usually continue below the initiation threshold once started, until dialysis or transplant — see REN-01A.
Apixaban: standard dose to CrCl 30; caution and dose-reduction at CrCl 15–29 per eTG/specialist advice; avoid below CrCl 15.
Opioids: reduce dose at eGFR 30–60 (oxycodone often preferred); avoid morphine below eGFR 30, favour oxycodone/buprenorphine.
Antibiotics: gentamicin and vancomycin need dose/interval adjustment below eGFR 60 — check AMH/eTG for exact dosing.
NSAIDs: avoid at eGFR 30–60; absolutely avoid below eGFR 30.

Check exact doses at AMH/eTG

These are general bands, not exact mg doses. Confirm precise renal dosing for the individual drug and indication in the Australian Medicines Handbook or eTG before prescribing, particularly for antibiotics and opioids.

Safety

NSAIDs are a major preventable cause of acute kidney injury in CKD, especially combined with an ACEi/ARB and a diuretic — avoid wherever possible.
Confirm potassium ≤5.0 mmol/L before starting finerenone or up-titrating any RAS blocker/MRA combination.
Discuss alternatives to IV contrast if eGFR<30.

Red flags / refer

eGFR<30 (Stage 4–5) → nephrology referral, all patients.
Albuminuria uACR≥30 mg/mmol (Stage A3) → nephrology referral.
Rapid decline, suspected AKI/acute nephritis, or resistant hypertension despite ≥3 agents → nephrology referral — see REN-01A for exact decline thresholds.

REN-01B v1.0 · Reviewed Jun 2026 · Review Jun 2027

For health-professional use. Framework: KDIGO 2024 CKD Guideline; Kidney Health Australia CKD Management in Primary Care (5th ed, 2024). Companion sheet: REN-01A CKD — Detection & the Treatment Pyramid.