Finding the missing millions with CKD

From early detection to screening and medicine management – pharmacists are increasingly involved in reducing the burden of kidney disease.

Chronic kidney disease (CKD) is a common but often ‘silent’ condition. One in three Australians are at risk of developing progressive CKD resulting from comorbidities such as hypertension, diabetes and cardiovascular disease. And most people are asymptomatic until significant kidney damage has occurred.

Familiarity with patients’ medical history equips pharmacists to act as first identifiers of potential CKD and to suggest Kidney Health Checks – which can find CKD in time to better manage the condition. People with diabetes, hypertension, family history of kidney disease, or those who are over 18 and from an Aboriginal and Torres Strait Islander family should have annual Kidney Health Checks. Current smokers and people with other risk factors, such as cardiovascular disease or obesity, should have Kidney Health Checks every 2 years.

Screening for CKD

A trial of CKD screening by pharmacists is currently underway across Australia, covering nearly 1,500 patients in 192 community pharmacies.

According to the University of Sydney’s Associate Professor Ron Castelino, a practising renal pharmacist at Blacktown Hospital, the trial was inspired by the discrepancy between the routine kidney function test results available to hospital pharmacists – who can then adjust doses of medicines cleared by the kidneys – and the lack of information available to community pharmacists.

The pilot first required pharmacists to assess patients’ likelihood of developing CKD using a series of questions about their risk factors. Around 30% of the patients in the recruitment pool were assessed as having a moderate to severe risk of developing CKD within 5 years. They were offered a point-of-care kidney function test, which is essentially a finger-prick test similar to the glucometer test used to manage diabetes, A/Prof Castelino says.

The point-of-care test provides an immediate reading of the patient’s estimated glomerular filtration rate (eGFR) and levels of serum creatinine to measure how well the kidneys are filtering waste from the blood. Patients identified as having impaired kidney function are referred to their general practitioner (GP) for more comprehensive blood and urine tests, spaced over at least 3 months, to diagnose CKD, he adds.

‘There are two or three benefits that I see straight away with the point-of-care device screening, particularly in rural and remote areas where pharmacy is more accessible,’ A/Prof Castelino says.

‘Patients can walk in and get the finger-prick test as the initial screening. Those who do come up with a decline in kidney function can be referred to the doctor straightaway, so that’s a massive positive. It’s also a good opportunity for pharmacists to see whether the dosage of medicines cleared by the kidneys may need to be adjusted.’

Management in pharmacy

Pharmacists’ therapeutic knowledge puts them in a unique position to help people manage CKD. A recent systematic review and meta-analysis of randomised controlled trials – including adults with a diagnosis of CKD and those with and without kidney replacement therapy – found pharmacist interventions resulted in statistically significant improvements
in systolic blood pressure and haemoglobin levels.⁵

But the findings showed pharmacist interventions had mixed results for various outcomes, according to the scientists. ‘Future studies should be more robustly designed and take into consideration the role of the pharmacist in prescribing and deprescribing, the findings of which will help inform research and clinical practice,’ they concluded.⁵

Kidney care for Aboriginal and Torres Strait Islander peoples

Chronic kidney disease is prevalent among Aboriginal and Torres Strait Islander peoples.⁶ Breonny Robson, Kidney Health Australia’s General Manager, Clinical and Research, says pharmacists should familiarise themselves with the Caring for Australians and New Zealanders with Kidney Impairment (CARI) recommendations for providing culturally safe kidney care in Aboriginal and Torres Strait Islander peoples.⁷

‘Pharmacists should also ensure pharmacy staff undertake formal cultural safety training and establish that they have referral pathways for First Nations peoples back to their local Aboriginal Community Controlled Health Organisations (ACCHOs) and GP to ensure continuity of care,’ she says.

‘First Nations peoples should be encouraged to have their annual 715 health check [the Medicare number for a comprehensive health check], ensure that they are correctly identified as Aboriginal and/or Torres Strait Islander at the service and that they are correctly enrolled in the Closing the Gap program.’⁸

Ms Robson adds that pharmacists should discuss potential point-of-care testing and in-pharmacy screening with the local ACCHO, so that community members are linked to their regular health service for continuity of care.

Pharmacists supporting CKD treatment

CKD usually entails ‘super-polypharmacy’.⁹ With patients often managing 16–20 medicines, pharmacists have a vital role to play in medicines review, dose adjustment and transplant support.

Hanh Tran, Senior Pharmacist (Renal) at Royal Adelaide Hospital, says polypharmacy is a significant challenge in CKD due to patients’ unstable renal function, their frequent medicines changes, and the involvement of multiple specialists (including endocrinologists, cardiologists and GPs).

‘Patients often experience “pill burden” and contradictory advice,’ she says. ‘A classic example is calcium: commonly prescribed as a phosphate binder in CKD, it must be taken with food to bind dietary phosphate – which is contrary to the usual advice for calcium supplementation.’

Renal dosing principles include maintaining medicine records, providing patients with updated lists of medicines, and ensuring they are equipped to manage complex medicines regimens.

Ms Tran says that dosing advice should be provided to relevant healthcare providers, including doctors, nurses and nurse practitioners.

Meanwhile, people living with CKD in rural and regional areas may have limited access to nephrology services or dialysis centres.¹⁰ Gauri Godbole FPS, a specialist aged care pharmacist at Gosford Hospital, says that in cases of patients with advanced CKD requiring polypharmacy, it’s important to ‘prioritise medicines with clear evidence of benefit that are aligned to patient goals, and ensure renal-appropriate dosing’.

Identifying the patient’s best possible medication history, including the over-the-counter and herbal products they take, is the first step, she says. Ms Godbole then identifies the high-risk or nephrotoxic medicines and recommends dose adjustments or, in certain cases, discontinuation, based on renal function and clinical benefit.

‘Goals of care often evolve over time, serving as an important catalyst for deprescribing,’ she says.

‘We identify nephrotoxic, duplicate or low-value medicines for deprescribing, especially where benefits are limited in advanced illness. Tools such as STOPP/START, STOPPFrail and STOPPCog, alongside multidisciplinary input and shared decision-making, support tailored recommendations. Deprescribing should be monitored with regular follow-up, symptom checks, and tapering if needed.’

The Australian Pharmaceutical Formulary and Handbook (APF) supports the concept of deprescribing in patients with progressive CKD where the benefit of long-term preventive medicines (such as statins in the elderly) may no longer outweigh the risks. Deprescribing should also be considered for medicines with narrow therapeutic windows or renal toxicity such as lithium, NSAIDs, metformin and SGLT2 inhibitors (depending on eGFR).¹¹

The APF recommends assessing kidney function before adjusting dosages and referencing renal dosing guides when determining dose changes. It also recommends avoiding or reducing the dosage of nephrotoxic drugs such as NSAIDs and aminoglycosides, and advises special caution with drugs cleared renally – including metformin (which carries a risk of lactic acidosis), digoxin and DOACs (such as apixaban).¹¹

Providing transplant support

Community pharmacists can provide essential support for kidney transplant recipients in regional, rural and remote areas of Australia.¹² Renal transplant pharmacists in hospitals play a vital role within the transplant team, supporting recipients throughout their journey from surgery to long-term post-transplant care, with a strong focus on medicine management, Ms Tran says.

Renal hospital pharmacists are available in both inpatient and outpatient settings to answer patients’ questions, troubleshoot issues related to specialised medicines and provide guidance on new therapies, she adds. They provide support to ensure changes in medicines are made safely and are tailored to each patient’s needs. Renal pharmacists can also provide the patient with information about kidney medicines and initiate suitable and tailored support.

This can be done in inpatient wards, outpatient clinics and via telehealth, with renal pharmacists able to help relieve CKD symptoms such as water retention, swelling, common uraemic symptoms (itchiness, muscle cramps, fatigue and weakness, ongoing nausea and poor appetite, deterioration in memory), and chronic neuropathic pain.

At bigger hospitals, renal pharmacists work with dialysis units to ensure renal medicines such as erythropoietin injections, dialysis-related blood thinners and iron infusions are appropriately supplied and used safely, Ms Tran adds.

‘Patients who are new to dialysis receive a comprehensive medication review to ensure their current medicines are still suitable for dialysis,’ she says.

‘Patients receive thorough education about how and why some medicines would be dialysed or interact with dialysis, and how and why blood and antidiabetic medication requirements could significantly change when a patient is undergoing dialysis.’

Trials have found that optimal medicine use can significantly reduce the risk of kidney failure while also contributing to the delay or prevention of dialysis.

‘SGLT2 inhibitors can significantly slow the progression of CKD and reduce the risk of needing dialysis in patients with and without type 2 diabetes,’ a meta-analysis research paper concluded. ‘These effects were shown consistently across groups with varying baseline eGFR values.’ ¹³ 

The future of pharmacy care

As the medicines experts in the healthcare team, pharmacists are essential for ensuring safe and effective pharmacotherapy in kidney disease patients, Ms Robson says.

‘Besides the traditional roles of verifying dose accuracy and reviewing drug interactions, pharmacists can recommend treatments – such as ACE inhibitors and SGLT2 inhibitors – that have been shown to slow the progression of kidney disease,’ she says.

Pharmacists can also offer self-management counselling, review the potential symptoms of worsening kidney function, provide advice on adverse effects from medicines, and assist with strategies for medicine adherence, she adds.

‘At Kidney Health Australia, we welcome any initiative that will improve outcomes for people living with kidney disease – it is absolutely necessary that we place greater focus on the early detection, diagnosis and management of CKD, and pharmacists are well placed to do this,’ Ms Robson says.

‘Kidney Health Australia has recently partnered with the Pharmaceutical Society of
Australia to deliver educational programs to primary care providers and pharmacists in the community, stressing the need for at-risk patients to get a Kidney Health Check.’

Patient care and screening initiatives in community pharmacy, she adds, will allow pharmacists to play a key role in supporting Kidney Health Australia’s goal of ending
dialysis by 2050. 

References

1. Kidney Health Australia. Symptoms of kidney disease. At: https://kidney.org.au/your-kidneys/what-is-kidney-disease/symptoms-of-kidney-disease
2. National Kidney Foundation. Pharmacists and chronic kidney disease. At: https://www.kidney.org/professionals/ckdintercept/pharmacists-and-chronic-kidney-disease
3. Kidney Health Australia. Kidney health check. At: https://kidney.org.au/your-kidneys/know-your-kidneys/know-the-risk-factors/kidney-health-check
4. Tesfaye W, Krass I, Sud K, Johnson DW, Van C, Versace VL, et al. Impact of a pharmacy-led screening and intervention in people at risk of or living with chronic kidney disease in a primary care setting: a cluster randomised trial protocol. BMJ Open. 2023;13(12):e079110. At: https://bmjopen.bmj.com/content/13/12/e079110. BMJ Open
5. Ardavani A, Curtis F, Hopwood E, et al. Effect of pharmacist interventions in chronic kidney disease: a meta-analysis. Nephrol Dial Transplant. 2025;40(5):884–907. At: https://academic.oup.com/ndt/article/40/5/884/7816383
6. Australian Indigenous HealthInfoNet. Latest information and statistics on kidney health. At: https://healthinfonet.ecu.edu.au/learn/health-topics/kidney/latest-information-and-statistics-on-kidney-health/
7. CARI Guidelines. First Nations Australian guidelines. At: https://www.cariguidelines.org/first-nations-australian-guidelines/
8. Closing the Gap. At: https://www.closingthegap.gov.au
9. Oosting IJ, Colombijn JMT, Kaasenbrood L, Liabeuf S, Laville SM, Hooft L, et al. Polypharmacy in patients with CKD: a systematic review and meta-analysis. Kidney360. 2024;5(6):841–850. At: https://pubmed.ncbi.nlm.nih.gov/38661553/. ScienceDirect+1
10. Wright J, Glenister KM, Thwaites R, Terry D. The importance of adequate referrals for chronic kidney disease management in a regional Australian area of nephrologist workforce shortage. Aust J Gen Pract. 2018;47(1–2):58–62. At: https://www1.racgp.org.au/ajgp/2018/january-february/the-importance-of-adequate-referrals-for-chronic-k
11. Pharmaceutical Society of Australia. Australian Pharmaceutical Formulary. At: https://www.psa.org.au/media-publications/australian-pharmaceutical-formulary/
12. Watters TK, Scholes-Robertson NJ, Mallett AJ, Glass BD. Exploring the pharmacist’s role in regional, rural, and remote kidney transplant care: Perspectives of health professionals and transplant recipients. Explor Res Clin Soc Pharm. 2025;18:100587. doi:10.1016/j.rcsop.2025.100587. PMID: 40177655; PMCID: PMC11964747
13. Mahendra AI, Samsu N, Gunawan A, Rifai A. SGLT-2 inhibitors delay kidney failure progression and reduce need of dialysis in chronic kidney disease patients: a meta-analysis. Nephrol Dial Transplant. 2023;38(Supplement_1):gfad063c_2934. At: https://academic.oup.com/ndt/article/38/Supplement_1/gfad063c_2934/7196059