Palliative Care in Chronic Kidney Disease

Last updated 1 Jun 2026 · Palliative care

📋 Key Information Summary

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Palliative care should be integrated early in advanced CKD (stages 4–5) alongside active disease management, not reserved for the final days of life.
Conservative kidney care (CKC) is a valid, patient-centred treatment pathway for selected patients with CKD stage 5 who choose not to commence dialysis.
Shared decision-making using tools such as the Australian Renal Supportive Care guidelines is essential when discussing dialysis versus conservative management.
Dialysis withdrawal accounts for approximately 20% of deaths in Australian dialysis patients and requires careful symptom planning, family support, and palliative care involvement.
Uraemic symptoms — including pruritus, nausea, anorexia, fatigue, restless legs, and cognitive impairment — significantly impair quality of life and require proactive pharmacological and non-pharmacological management.
Medication review is mandatory in advanced CKD; renally cleared drugs require dose adjustment or avoidance, and deprescribing should follow structured frameworks (e.g., STOPPFrail, STOPP/START).
Opioid use in CKD requires caution: avoid morphine and codeine; preferred agents include hydromorphone, fentanyl, and methadone with appropriate dose reduction.
Advance care planning (ACP) should be documented using state-based frameworks (e.g., Advance Care Directive in SA, Resuscitation Plan in NSW) and revisited regularly.
Aboriginal and Torres Strait Islander Australians with CKD experience disproportionately higher rates of ESKD and face barriers to palliative care access, requiring culturally safe, community-based approaches.
The palliative care team, nephrology team, GP, and community services must collaborate using a multidisciplinary model; referral to specialist palliative care is indicated for complex symptom management.
After dialysis withdrawal, median survival is 8–12 days; anticipatory prescribing of subcutaneous medications for pain, dyspnoea, nausea, and agitation is essential.
Renal dietitian, social work, and spiritual care support are integral components of the CKD palliative care multidisciplinary team.

Introduction & Australian Epidemiology

Chronic kidney disease (CKD) affects approximately 1.7 million Australians, with prevalence increasing with age and among Aboriginal and Torres Strait Islander peoples. As CKD progresses to stage 4–5 (estimated glomerular filtration rate [eGFR] <30 mL/min/1.73 m²), the burdens of treatment — particularly dialysis — may outweigh benefits for some patients. Palliative care in CKD encompasses symptom management, advance care planning, shared decision-making regarding dialysis initiation or withdrawal, conservative kidney care pathways, and end-of-life care.

The Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) reports that approximately 12,000 Australians receive maintenance dialysis. Withdrawal from dialysis accounts for roughly 20% of all deaths in this population, making it one of the leading causes of dialysis-related mortality. Despite this, palliative care referral rates among nephrology patients remain lower than in oncology, highlighting an unmet need.

Palliative care in CKD differs from cancer palliative care in several key ways: the trajectory is often unpredictable with episodic deterioration and partial recovery; uraemic symptoms overlap with medication side effects; and patients frequently retain decision-making capacity until close to death. This demands a flexible, integrated model where supportive care commences alongside active nephrological management, not as a sequential step after "all options are exhausted."

The Kidney Health Australia–Caring for Australasians with Renal Impairment (KHA-CARI) guidelines, the Australian and New Zealand Society of Nephrology (ANZSN), and the Palliative Care Australia standards all support early integration of palliative care in CKD management. This article provides an evidence-based framework for clinicians managing patients with advanced CKD who may benefit from a palliative or supportive care approach.

Conservative Kidney Care

Conservative kidney care (CKC) is a planned, comprehensive treatment pathway for people with CKD stage 5 who choose not to commence dialysis, or for whom dialysis is unlikely to confer meaningful benefit. CKC is not "doing nothing" — it is an active, multidisciplinary approach focused on prolonging life where possible, managing symptoms, preserving quality of life, and supporting end-of-life care.

ℹ️

CKC is a valid treatment choice: Australian data (Morton et al., 2010) demonstrate that selected elderly patients with significant comorbidities who choose CKC have survival and quality-of-life outcomes comparable to those who commence dialysis, particularly in the first 12 months.

Who Is CKC Appropriate For?

CKC is most appropriate when the anticipated survival benefit from dialysis is small and the treatment burden is high. Indications include:

Age >80 years with multiple comorbidities (particularly ischaemic heart disease, diabetes, frailty)
WHO performance status 3–4 or Clinical Frailty Scale ≥5
Severe irreversible comorbid conditions (e.g., advanced dementia, metastatic cancer, severe heart failure)
Patient preference after informed, shared decision-making
Limited vascular access or peritoneal dialysis feasibility

Components of CKC

Symptom Management

Proactive management of uraemic symptoms (pruritus, nausea, fatigue, dyspnoea, restless legs) with regular symptom assessment using validated tools such as the POS-S Renal or IPOS-Renal.

Fluid and Electrolyte Management

Dietary counselling (potassium, sodium, fluid restriction), diuretics (frusemide 80–250 mg PO daily), management of metabolic acidosis with sodium bicarbonate 500 mg–1 g PO TDS.

Anaemia Management

ESAs and iron supplementation per KHA-CARI guidelines if symptomatic benefit; consider stopping if quality-of-life gains are marginal. Target Hb 100–115 g/L.

Advance Care Planning

Document preferences regarding hospitalisation, resuscitation, ICU admission, and preferred place of death. Engage family/whānau and substitute decision-makers early.

Multidisciplinary Support

Renal dietitian, social worker, palliative care nurse, Aboriginal health worker (for ATSI patients), spiritual care, and GP coordination. Home-based care where possible.

Medications to Continue in CKC

Medication Class	Purpose	Notes
Antihypertensives	Blood pressure control, symptom relief	May simplify regimen; avoid over-treatment causing hypotension
Diuretics (frusemide)	Fluid overload, dyspnoea	Higher doses often required (125–250 mg PO daily); monitor electrolytes
Phosphate binders	Pruritus prevention, vascular calcification	Calcium carbonate 500 mg PO with meals; sevelamer if intolerant
Sodium bicarbonate	Metabolic acidosis	500 mg–1 g PO TDS; reduces muscle wasting and dyspnoea
ESAs (if on treatment)	Symptomatic anaemia	Continue if quality-of-life benefit evident; cease if futility
Active vitamin D	Bone health, PTH suppression	Calcitriol 0.25 mcg PO daily; monitor calcium

Medications to Deprescribe in CKC

Statins — unlikely to provide benefit in limited life expectancy
Proton pump inhibitors — review ongoing indication
Antiplatelet agents — unless clearly indicated for symptom management
Allopurinol — unless active gout
Supplements (folate, B-vitamins) — review necessity

Dialysis Withdrawal

Dialysis withdrawal is the planned cessation of maintenance dialysis in patients for whom ongoing dialysis no longer aligns with their goals of care. ANZDATA data indicate that approximately 20% of deaths in Australian dialysis patients follow dialysis withdrawal, and this proportion increases with age. It is a legitimate, ethically supported medical decision that requires careful communication, multidisciplinary support, and robust symptom management.

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Legal and ethical framework: In Australia, a competent patient has the legal right to refuse or withdraw from any treatment, including dialysis. This is supported by common law and state-based guardianship legislation. Clinicians must ensure the patient has decision-making capacity, adequate information, and is free from coercion. If capacity is impaired, the substitute decision-maker (as per relevant state legislation) should be involved.

Indications for Dialysis Withdrawal

Patient request after informed discussion about goals of care
Increasing frailty with dialysis-associated complications (recurrent hospitalisations, intradialytic hypotension, access failures)
Progressive cognitive decline or dementia limiting quality of life
Severe vascular access exhaustion with no further options
Intercurrent illness making ongoing dialysis futile (e.g., advanced malignancy, severe stroke)

The Withdrawal Process

Pre-withdrawal

Multidisciplinary meeting with nephrologist, palliative care team, renal nurse, social worker, patient, and family. Discuss goals, symptom plan, and preferred place of care/death. Document advance care plan. Commence anticipatory medications.

Day 0 (Final dialysis)

Final haemodialysis session if in-centre, or removal of PD catheter if peritoneal dialysis. Dialysis line left in situ if required for symptom management access. Discharge to preferred setting if feasible.

Days 1–3

Onset of uraemic symptoms: nausea, anorexia, drowsiness. Commence or titrate symptom management medications. Regular nursing review (daily or more frequently). Family/whānau support.

Days 3–7

Increasing somnolence, reduced oral intake. Transition to subcutaneous route for medications. Maintain oral care, skin integrity. Spiritual and psychological support for patient and family.

Days 7–14+

Deepening coma. Terminal phase management with continuous subcutaneous infusions. Median survival after dialysis withdrawal: 8–12 days (range 1–28 days). Bereavement support for family initiated.

Anticipatory Prescribing — Post-Withdrawal Symptom Management

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Hydromorphone

Dilaudid® · Opioid analgesic

Adult dose 0.5–1 mg SC Q4H PRN, titrate to effect; or 1–4 mg/24h CSCI via syringe driver

Notes Preferred opioid in CKD — no active toxic metabolites. Avoid morphine (M6G accumulation).

PBS status ✔ PBS General Benefit

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Fentanyl

Sublimaze® · Opioid analgesic

Adult dose 25–50 mcg SC Q1–2H PRN; or 25–100 mcg/24h CSCI. Transdermal: 12 mcg/hr patch (if stable pain).

Notes Useful in renal failure; hepatic metabolism, no renally active metabolites. Patch onset 12–24 hours — not for acute titration.

PBS status ✔ PBS General Benefit

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Haloperidol

Serenace® · Antiemetic / antipsychotic

Adult dose 0.5–2.5 mg SC Q6–8H PRN for nausea/vomitation or terminal agitation; or 2.5–10 mg/24h CSCI Notes First-line for uraemic nausea and terminal agitation. No renal adjustment required. Monitor for extrapyramidal effects.

PBS status ✔ PBS General Benefit

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Midazolam

Hypnovel® · Benzodiazepine

Adult dose 2.5–5 mg SC PRN for dyspnoea or terminal restlessness; or 10–30 mg/24h CSCI. Titrate in 2.5–5 mg increments.

Notes First-line for terminal dyspnoea and refractory agitation. Use lowest effective dose. Hepatic metabolism — no renal dose adjustment.

PBS status ✔ PBS General Benefit

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Hyoscine butylbromide

Buscopan® · Anticholinergic

Adult dose 20 mg SC Q4–6H PRN for secretions; or 60–120 mg/24h CSCI

Notes For noisy respiratory secretions ("death rattle"). Does not cross blood-brain barrier (minimal sedation). Glycopyrrolate 0.2 mg SC alternative.

PBS status ✔ PBS General Benefit

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Syringe driver (CSCI) compatibility: When combining medications in a subcutaneous continuous infusion (e.g., Graseby syringe driver), check compatibility charts. Common combinations: hydromorphone + haloperidol + midazolam + hyoscine butylbromide. Replace every 24 hours. Site: anterior thigh or anterior abdominal wall. Use 0.9% NaCl as diluent.

Uraemic Symptoms

Uraemic symptoms are a direct consequence of toxin accumulation in advanced CKD and significantly impair quality of life. Patients with CKD stage 5 not on dialysis experience a median of 8–12 symptoms concurrently. Proactive, systematic symptom assessment and management is a cornerstone of CKD palliative care. Validated tools include the Integrated Palliative Care Outcome Scale — Renal (IPOS-Renal) and the Palliative Care Outcome Scale — Symptoms — Renal (POS-S Renal).

Common Uraemic Symptoms and Management

Symptom	Prevalence	First-Line Management	Second-Line / Refractory
Fatigue	70–90%	Exercise programme, sleep hygiene, treat anaemia (ESAs if indicated), correct iron deficiency	Methylphenidate 2.5–5 mg PO mane (specialist); address depression
Pruritus	40–70%	Emollients (sorbolene ± glycerol), phosphate binders, optimise dialysis if on RRT	Gabapentin 100 mg PO post-dialysis or 100 mg PO nocte (renal dose); pregabalin 25 mg PO alternate nights; UVB phototherapy
Nausea / Vomiting	30–60%	Haloperidol 0.5–1.5 mg PO/SC TDS; metoclopramide 10 mg PO TDS (max 3 days in elderly)	Ondansetron 4 mg PO/SC BD (QTc monitoring); cyclizine 50 mg PO/SC TDS; dexamethasone 4–8 mg IV/SC mane
Anorexia	30–50%	Small frequent meals, relaxed diet liberalisation in CKC, nutritional supplements, dietary counselling	Prednisolone 5–10 mg PO mane (short course); megestrol 160 mg PO daily (limited evidence)
Restless Legs Syndrome	20–40%	Iron studies — replete ferritin >200 mcg/L; gabapentin 100–300 mg PO nocte (renally adjusted)	Clonazepam 0.5 mg PO nocte (short-term); pramipexole 0.088 mg PO nocte (specialist, not PBS-listed for RLS)
Dyspnoea	30–50%	Frusemide 80–250 mg PO/IV daily; fluid restriction; fan therapy; positioning	Low-dose morphine 2.5–5 mg PO BD (only if no alternative; monitor closely for toxicity); midazolam 2.5 mg SC PRN for refractory dyspnoea
Cognitive Impairment / "Brain Fog"	30–50%	Treat contributing factors (uraemia, medications, infection, electrolyte disturbance); simple environmental strategies	Review all CNS-active medications; consider dialysis initiation if reversible component suspected and aligns with goals
Pain	40–60%	Paracetamol 1 g PO QDS (no renal adjustment); topical NSAIDs; simple measures	Hydromorphone 0.5–1 mg PO/SC Q4H; gabapentin for neuropathic pain; avoid morphine and codeine

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Neuropathic pain in CKD: Gabapentin requires significant dose reduction in CKD. For eGFR <15 mL/min: gabapentin 100 mg PO after dialysis or on alternate days. Pregabalin: 25 mg PO alternate days for eGFR <15 mL/min. Failure to adjust doses risks sedation, respiratory depression, and falls.

Symptom Assessment Tools

IPOS-Renal — Integrated Palliative care Outcome Scale adapted for renal patients. Covers physical symptoms, psychological concerns, and information needs. Free to use. Recommended for use at each clinic visit in CKC.
POS-S Renal — Palliative Outcome Score — Symptoms — Renal. Short symptom severity tool. Validated in the Australian CKD population.
Edmonton Symptom Assessment System — Revised (ESAS-r) — Widely used in palliative care; can be applied to CKD populations. Nine symptoms scored 0–10.

Medication Adjustment in Advanced CKD

Medication management in advanced CKD (stages 4–5, eGFR <30 mL/min/1.73 m²) and particularly in CKC or post-dialysis withdrawal requires careful review. Reduced renal clearance leads to drug and metabolite accumulation, increasing toxicity risk. A systematic deprescribing approach, combined with appropriate dose adjustment of essential medications, is a core skill in CKD palliative care.

Principles of Medication Adjustment

Conduct a Full Medication Review

List all medications including OTC, supplements, and complementary medicines. Assess each for ongoing indication, dose appropriateness, and potential for toxicity. Use deprescribing frameworks (STOPPFrail criteria, Beers Criteria).

Identify Medications Requiring Avoidance

Certain drugs are contraindicated or carry high risk in CKD 5 and must be ceased or substituted. See table below.

Dose-Adjust Remaining Medications

Reduce dose or extend interval for renally cleared drugs. Consult Australian Medicines Handbook (AMH) renal dosing guide. Consider that without dialysis, no drug clearance occurs.

Switch to Safer Alternatives

Replace nephrotoxic or accumulation-prone drugs with renal-safe alternatives (e.g., hydromorphone instead of morphine; paracetamol instead of NSAIDs).

Monitor and Reassess Regularly

Symptom burden and medication needs change as CKD progresses or after dialysis withdrawal. Review at each clinical encounter. Involve a clinical pharmacist where available.

Drugs to Avoid or Use with Extreme Caution in CKD Stage 5 / CKC

Drug / Class	Reason for Avoidance	Safer Alternative
Morphine	Active metabolite (M6G) accumulates → respiratory depression, excessive sedation, myoclonus	Hydromorphone 0.5 mg SC/PO Q4H; fentanyl 25 mcg SC Q1–2H
Codeine	Metabolised to morphine; unpredictable accumulation	Tramadol 25–50 mg PO BD (max, with monitoring) or hydromorphone
NSAIDs (oral)	Nephrotoxic, hyperkalaemia, GI bleeding, fluid retention	Paracetamol 1 g PO QDS; topical NSAIDs for localised pain
Metformin	Lactic acidosis risk; contraindicated eGFR <15	Insulin (reduced doses); gliclazide 40–80 mg PO daily (short-acting sulfonylurea)
Gabapentin (unadjusted)	Accumulation → sedation, respiratory depression, falls	100 mg PO after dialysis or on alternate days for eGFR <15
Digoxin	Renally cleared; narrow therapeutic index	Reduce dose by 50%; monitor levels (target 0.5–0.8 mcg/L); or cease if no clear indication
Colchicine	Severe toxicity risk in renal impairment	Avoid; corticosteroids for acute gout flares
Pregabalin (unadjusted)	Accumulation in renal failure	25 mg PO alternate nights for eGFR <15; monitor sedation

Key Medication Adjustments in CKD Stage 5

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Gabapentin

Neurontin® · Anticonvulsant / neuropathic pain / pruritus

Normal dose 300–600 mg PO TDS

CKD 5 (eGFR <15) 100 mg PO after each dialysis session, or 100 mg PO on alternate days if not on dialysis

Renal adjustment Essential — severe accumulation and toxicity risk if not adjusted

PBS status ✔ PBS General Benefit

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Tramadol

Tramal® · Weak opioid / neuropathic pain

Normal dose 50–100 mg PO Q4–6H

CKD 5 (eGFR <15) 25–50 mg PO BD; max 50 mg Q12H. Extended-release formulations contraindicated.

Renal adjustment Essential — active metabolite M1 accumulates. Seizure risk at high levels.

PBS status ✔ PBS General Benefit

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Ondansetron

Zofran® · 5HT3 antagonist antiemetic

Normal dose 4–8 mg PO/IV TDS

CKD 5 (eGFR <15) 4 mg PO/SC BD–TDS. No specific dose reduction in product information, but use lowest effective dose.

Renal adjustment Monitor QTc interval. Prefer haloperidol as first-line in CKD nausea.

PBS status ✔ PBS General Benefit

Deprescribing Framework

When transitioning to CKC or palliative care, consider deprescribing the following categories systematically:

Category	Action	Rationale
Statins	Cease	No benefit in limited life expectancy; polypharmacy burden
Bisphosphonates	Cease	Contraindicated in severe CKD; risk of adynamic bone disease
Potassium-sparing diuretics	Cease or monitor closely	Hyperkalaemia risk; consider loop diuretics instead
ACEi / ARBs	Cease if symptomatic hypotension or hyperkalaemia	May continue if BP and K⁺ allow; deprescribe if causing symptoms
Warfarin / DOACs	Review indication	Bleeding risk increases; deprescribe unless strong AF or VTE indication and patient wishes to continue
Oral diabetes agents	Simplify	Liberalise glycaemic targets (HbA1c <75 mmol/mol); avoid hypoglycaemia; switch to insulin if needed
Phosphate binders	Continue if symptomatic benefit	Pruritus and bone pain may improve; cease if no benefit

Special Populations

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Pregnancy

CKD in pregnancy is rare at stage 5; if it occurs, manage in a tertiary centre with nephrology and obstetric teams.

Many palliative medications are teratogenic or poorly studied: haloperidol, gabapentin, and benzodiazepines carry risk — discuss with maternal-fetal medicine.

Advance care planning must consider the fetus as a separate patient; ethical frameworks should guide decision-making.

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Paediatrics

Paediatric CKD palliative care is uncommon but critically important when it arises (congenital renal dysplasia, posterior urethral valves).

Dosing is weight-based: hydromorphone 10–20 mcg/kg SC Q4H; midazolam 50–100 mcg/kg SC PRN.

Family-centred care; involve paediatric palliative care team (e.g., Bear Cottage, Very Special Kids). Sibling support is essential.

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Elderly (>75 years)

The majority of CKC patients are aged >75. Frailty assessment (Clinical Frailty Scale) should guide treatment decisions.

Lower starting doses for all psychoactive medications. Haloperidol 0.25–0.5 mg SC/PO. Increased falls risk — review sedating agents.

Polypharmacy is the norm — conduct structured medication review at each visit. Engage aged care services and My Aged Care if applicable.

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Renal Impairment

All patients in this article have advanced CKD — this is the defining population. Key principle: without dialysis, renally cleared drugs have NO clearance pathway.

Avoid morphine, codeine, gabapentin at standard doses, NSAIDs, and colchicine. Review every medication for renal clearance pathway.

Use AMH renal dosing guide. Clinical pharmacist involvement reduces adverse drug events by up to 40%.

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Hepatic Impairment

Hepatorenal syndrome or concurrent liver disease complicates medication management. Many "renal-safe" opioids are hepatically metabolised.

In combined renal-hepatic failure, fentanyl and midazolam require dose reduction (start at 50% of usual dose). Haloperidol generally safe.

Avoid hepatotoxic drugs; monitor LFTs. Use Child-Pugh score to guide hepatic dose adjustments.

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Immunocompromised

Transplant recipients returning to dialysis or CKC after graft failure have unique needs: immunosuppression withdrawal, infection risk, and malignancy surveillance.

Withdraw calcineurin inhibitors gradually. Prednisolone taper per transplant protocol. Monitor for rejection symptoms even in graft failure.

Increased infection risk — low threshold for empirical antibiotics. Consider CMV and BK virus reactivation.

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Health

Aboriginal and Torres Strait Islander Australians experience a significantly disproportionate burden of kidney disease. ESKD incidence is approximately 6–8 times higher than in non-Indigenous Australians, with onset at a younger age (median age at ESKD diagnosis approximately 50 years vs 65 years). The burden is greatest in remote and very remote communities, particularly in the Northern Territory, Western Australia, and Far North Queensland. Diabetes is the primary driver, accounting for approximately 70% of Indigenous ESKD cases.

Palliative and supportive care for Aboriginal and Torres Strait Islander peoples with advanced CKD must be delivered in a culturally safe, trauma-informed, and community-centred manner. Historical distrust of the health system, experiences of racism, and the legacy of the Stolen Generations profoundly affect engagement with healthcare, including discussions around end-of-life care and dialysis decisions.

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Cultural safety is paramount: Concepts of "palliative care" and "withdrawal of treatment" may not translate directly into Aboriginal and Torres Strait Islander frameworks. Use culturally appropriate language (e.g., "comfort care," "looking after you well," "making you comfortable"). Involve family, Elders, and Aboriginal Health Workers/Practitioners in all discussions. Never initiate advance care planning without establishing trust and rapport first.

Key Considerations

Remote access

Many patients choose to return to remote communities for CKC or end-of-life care. Ensure adequate medication supply (28-day Remote Area Aboriginal Health Services supply), subcutaneous infusion equipment, and remote palliative care support via RFDS and CRANAplus. Telehealth nephrology and palliative care reviews are essential.

Family and community

Decision-making is often collective, involving extended family, Elders, and community. The concept of individual patient autonomy may not apply. Allow time and space for family discussions. Hospital environments may be culturally unsafe — support return to country where possible.

Sorry Business

Sorry Business (mourning and funeral practices) is a fundamental cultural obligation. When a patient is dying, extended family may travel long distances to be present. Clinicians should facilitate this — flexible visiting, extended family accommodation, and culturally appropriate spaces for ceremony.

Aboriginal Health Workers

Aboriginal Health Workers and Aboriginal Health Practitioners are essential members of the CKD palliative care team. They provide cultural brokerage, patient education, language interpretation, and community liaison. Funded positions should be embedded in renal and palliative care services.

Preferred place of care

Many Aboriginal and Torres Strait Islander patients express a strong preference to return to country for end-of-life care. This requires coordination with remote health services, medication continuity, and advance care documentation recognised across jurisdictions. The Northern Territory has specific advance care planning legislation.

Younger age and dialysis decision-making

Because ESKD occurs at a younger age, CKC discussions occur in patients who may have dependent children, employment, and community roles. Support services must address social determinants of health: housing, income, transport, and family welfare. Dialysis decisions should not be made solely on clinical grounds.

Resources

Kidney Health Australia — Culturally appropriate CKD patient resources and decision aids
RHDAustralia (Remote Area Health Corps) — Clinical guidelines for remote Aboriginal health
Palliative Care Australia — National Palliative Care Strategy with specific ATSI action plan
CRANAplus — Remote health workforce support and clinical resources
Aboriginal and Torres Strait Islander Kidney Health Strategy — Kidney Health Australia framework

📚 References

1. Kidney Health Australia. Chronic Kidney Disease (CKD) Management in Primary Care. 4th ed. Melbourne: Kidney Health Australia; 2020.
2. Morton RL, Tong A, Howard K, Snelling P, Webster AC. The views of patients and carers in treatment decision making for chronic kidney disease: systematic review and thematic synthesis of qualitative studies. BMJ. 2010;340:c112.
3. Murtagh FEM, Addington-Hall J, Edmonds P, et al. Symptoms in advanced renal disease: a cross-sectional survey of symptom prevalence in stage 5 chronic kidney disease patients managed without dialysis. J Palliat Med. 2007;10(6):1266–1276.
4. Davison SN, Levin A, Moss AH, et al. Executive summary of the KDIGO Controversies Conference on Supportive Care in Chronic Kidney Disease: developing a roadmap to improving quality of care. Kidney Int. 2015;88(3):447–459.
5. Australia and New Zealand Dialysis and Transplant Registry (ANZDATA). 46th Annual Report. Adelaide: ANZDATA; 2024.
6. Sellars M, Tong A, Luckett T, et al. Clinicians' perspectives on managing kidney failure in older people: a qualitative study. Nephrology. 2019;24(9):957–965.
7. Palliative Care Australia. National Palliative Care Strategy 2018. Canberra: Australian Government Department of Health; 2018.
8. Raj R, Ahuja K, Frandsen M, Jose M. Symptoms and their recognition in advanced chronic kidney disease: a review. Nephrology. 2022;27(3):215–227.
9. Australian Institute of Health and Welfare (AIHW). Chronic Kidney Disease in Aboriginal and Torres Strait Islander People. Cat. no. CDK 15. Canberra: AIHW; 2023.
10. Douglas CA, Monterosso L, Roberts M, et al. The supportive care and symptom management needs of patients with chronic kidney disease (the CKD-SMS study). J Pain Symptom Manage. 2023;65(3):e201–e210.
11. Brown MA, Collett GK, Josland EA, Foote C, Li Q, Brennan FP. CKD in elderly patients managed without dialysis: survival, symptoms, and quality of life. Clin J Am Soc Nephrol. 2015;10(2):260–268.
12. Galla JH. Clinical practice guideline on shared decision-making in the appropriate initiation of and withdrawal from dialysis. J Am Soc Nephrol. 2000;11(7):1340–1342.
13. Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int Suppl. 2013;3(1):1–150.
14. Selby NM, Casula A, Lamming L, et al. An organizational-level program of intervention for CKD: a systematic review. Kidney Int Rep. 2022;7(3):517–529.
15. Royal Australian College of General Practitioners (RACGP). A Guide to Deprescribing in Older People. Melbourne: RACGP; 2021.

for PBS scripts. Utilise ACCHS pharmacies and Remote Area Aboriginal Health Worker programs for medication supply in remote areas. Avoid initiating benzodiazepines; support holistic pain management including community-based exercise programs.

Preventive health

Promote bone health: encourage vitamin D supplementation (1000 IU daily in deficient individuals), smoking cessation support, reduction of alcohol intake, and weight-bearing exercise. MBS Item 715 health checks provide a structured opportunity to assess bone health, screen for osteoporosis risk factors, and discuss musculoskeletal health in a culturally safe context.

Quick Reference: Differential Diagnosis at a Glance

Costovertebral dysfunction

Paracetamol ± NSAID; manual therapy

2–6 weeks

Provocable on palpation; no red flags

Thoracic compression fracture

Paracetamol; ± calcitonin; DXA + osteoporosis Rx

6–12 weeks healing

Elderly; osteoporosis; acute onset

ACS (posterior MI)

Aspirin 300 mg, GTN, heparin; urgent PCI

Time-critical

ECG, troponin; CV risk factors

Aortic dissection

IV labetalol; urgent CT aortogram; surgery (Type A)

Time-critical

Tearing pain; BP differential >20 mmHg

Vertebral osteomyelitis

IV antibiotics (vancomycin + ceftriaxone initially); ID consult

6 weeks IV antibiotics

Fever, elevated CRP, IV drug use

Biliary colic / cholecystitis

Paracetamol ± morphine; lap cholecystectomy

Surgical within 72 h (cholecystitis)

RUQ/infrascapular; post-prandial; RUQ US

📚 References

1. Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10:77.
2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760–765.
5. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Europ Spine J. 2018;27(1):60–75.
6. Erwin WM, Jackson PC, Homonko DA. Innervation of the human costovertebral joint: implications for clinical back pain syndromes. J Manipulative Physiol Ther. 2000;23(6):395–403.
7. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
9. Erwin WM, Jackson PC. The costovertebral joint: anatomy, biomechanics, and clinical significance in thoracic back pain syndromes. J Can Chiropr Assoc. 2003;47(2):112–120.
10. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144–153.
11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
12. Lin CC, Chen KH, Li DM, et al. Characteristics and outcomes of patients presenting with thoracic back pain to the emergency department. Emerg Med Australas. 2020;32(5):805–811.

for PBS-listed medicines at participating pharmacies.

Cultural safety

Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.

Medication adherence

Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.

Specific conditions

Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.

Referral pathways

Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).

for PBS-listed medicines at participating pharmacies.

Cultural safety

Medication adherence

Specific conditions

Referral pathways

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).