Chronic disease management in Murrumbidgee

A local diabetes nurse and dietitian will personalise their education program specific for your needs.

They will work with you to achieve the best self-care management through the following steps to success:

• healthy eating
• being active
• monitoring your blood glucose levels (BGL)
• assist with medication management
• developing and supporting problem-solving skills and knowledge
• healthy approaches to coping with diabetes
• reducing risk factors that impact your health.

Our services are provided for all people with diabetes including:

• people with pre-diabetes symptoms
• those newly diagnosed with diabetes
• diabetes in pregnancy
• all age groups impacted by diabetes.

To make an appointment with a local diabetes nurse or a dietitian please contact the Community Care Intake Service on 1800 654 324.

The National Diabetes Services Scheme (NDSS) provides information that will improve and increase your knowledge on living with diabetes and accessing additional support.

• Type 1 diabetes support
• Type 2 diabetes support
• Gestational diabetes support
• Diabetes in pregnancy information
• Diabetes Australia
• Community Care Intake Referral form (PDF 230.19KB)
• Gestational Diabetes food and blood glucose monitoring diary (PDF 272.95KB)

Information is also available in different languages.

• we will maximise your wellness by preserving kidney function
• we use the lowest level of interventions possible
• we provide a standardised approach to accessing information for individuals and health care professionals
• we empower you to be actively engaged in the decision making and to take leadership with your care
• we aim for the best outcome, more choice and promote independence.

Chronic kidney disease (CKD)

Often, the development of kidney disease is gradual and kidney function worsens over a number of years. If you permanently lose more than one third of your kidney function, it is called ‘chronic kidney disease’ (CKD). This can lead to kidney failure.

You are more at risk of chronic kidney disease if you:

• have diabetes 
• have high blood pressure 
• are obese
• are over 60 years of age
• have a family history of end-stage kidney disease or hereditary kidney disease in a first or second degree relative
• have established heart problems (heart failure or a past heart attack) or have had a stroke
• smoke 
• have a history of acute kidney injury
• are Maori or Pacific Islander
• are Aboriginal or Torres Strait Islander.

The risk of CKD resulting in kidney failure depends on your level of kidney damage. If kidney disease is found early, medication, combined with diet and lifestyle changes, can prolong the life of your kidneys. 

If you have one or more of the risk factors for developing CKD, it is important to ask your doctor to check your kidney function.

Kidney failure

Kidney failure, also known as end-stage kidney disease, occurs when the kidneys are no longer able to adequately remove waste from your blood and control the level of fluid in the body. Kidney failure can happen suddenly or gradually.

You can lose up to 90 per cent of kidney function before feeling sick. In many cases, the signs of disease aren’t noticed until the kidneys are close to failure. 

People with kidney failure can have the following care:

• non-dialysis supportive care
• dialysis (renal replacement therapy)
• kidney transplant.

Renal Support Care in the Murrumbidgee LHD is provided by a multidisciplinary team and includes a renal nurse practitioner, dietitian and social worker support. The team work in collaboration with the treating nephrologist and general practitioner and refer to additional specialised services specific to individual need and to optimise quality of life and care management.

Nephrologist – Kidney Specialist (Doctor)

• General practitioners and primary health providers are responsible for regular kidney health checks with their patients.
• Appropriate referral to nephrologist care is associated with preserving kidney function for as long as possible so that the individual avoids the need for renal replacement therapy.
• After the initial consultation, the nephrologist will collaborate with specialist renal nurses and allied health staff to support individuals and their families in relation to their kidney disease.

Renal supportive care

• Renal supportive care (RSC) enhances choice of medical care for patients and their families. It is not meant to provide a system of care that competes with dialysis or in any way denies lifesaving treatment.
• This type of care is about improving the quality of life for many patients on dialysis and symptom management, as well as supporting patients who choose a conservative pathway or withdraw from treatment.

Chronic Kidney Disease nurse

The Chronic Kidney Disease (CKD) nurse is associated with preserving kidney function for as long as possible so that the individual avoids the need for renal replacement therapy.  The CKD nurse works in collaboration with the nephrologist to:

• reduced rates of progression to end stage kidney disease (ESKD)
• timely and proactive pre-dialysis education
• decreased need for and duration of hospitalisation
• increased likelihood of permanent dialysis access created prior to dialysis onset
• increased likelihood of kidney transplant
• decreased patient morbidity and mortality.

Dietitian

Renal dietitians specialise in the nutritional treatment and diet for patients with kidney disease.

The renal dietitian assists with the management of common symptoms associated with kidney disease including:

• symptom management: nausea, vomiting, taste changes, poor appetite, early satiety
• correcting abnormal blood results, in particular phosphate and potassium
• assessing overall physical and nutritional status
• manage medications, including phosphate binders and vitamins
• manage blood pressure (and fluid)
• diabetes education and management
• weight management (either, weight loss in preparation for transplant or maintaining /gaining weight in malnutrition).

Social Worker

Renal social workers assist renal patients throughout the course of their illness and treatment. The Social Worker will provide the follow to the patient and family:

• psychosocial assessment and case management to optimise patient quality of life
• counselling around decision to initiate dialysis, conservatory supportive treatment or withdraw from dialysis
• management of patient, family and carer distress
• access and referral to relevant social supports and patient advocacy
• care planning with the multidisciplinary team
• advice and assistance with advance care planning
• bereavement counselling. 

Aboriginal Healthcare worker

The Aboriginal Healthcare Worker collaborates with the renal multidisciplinary team to deliver high quality and accessible renal services to Aboriginal people and communities.

Renal replacement therapy (RRT) is treatment that replaces the normal blood-filtering function of the kidneys. It is used when the kidneys are not working well and an individual has kidney failure. Kidney failure can be from chronic kidney disease and from acute kidney injury.

Renal replacement therapy is commonly referred to as dialysis. There are 2 types of dialysis:

• peritoneal dialysis (fluid is placed in the tummy)
• haemodialysis (blood is cleaned by a machine) 

We promote “home first” models of renal replacement therapy (RRT) and encourage use of the renal supportive care (RSC) model.

Peritoneal dialysis (PD) is an alternative to haemodialysis and is undertaken at home. Referrals to the PD service is through the treating nephrologist and/or the CKD nurse.

There are two forms of PD:

1. Continuous Ambulatory Peritoneal Dialysis (CAPD) - A number of exchanges of fluid to and from the abdomen are performed each day manually
2. Automated Peritoneal Dialysis (APD) - A machine cycles fluids through the abdomen overnight.

The patient with a carer/buddy is trained for a period of 6-12 weeks to be able to perform haemodialysis at home.

After completion of haemodialysis training patients and carer/buddy are supported by the Home Training Unit and the Sydney Dialysis Centre (SDC) by an Outreach team.

A team of clinicians and allied health professionals who provide care at home or as close to home where possible to support those on home dialysis.

Opening hours:

Monday to Friday, 7am - 10pm
Saturday to Sunday, 7am - 3.30pm

Provides 20 chairs for acute and chronic haemodialysis In-centre service with ability to in-reach to Wagga Wagga Base Hospital. Home dialysis is also provided in a 4 Chair Training Unit.

Opening hours:

Monday to Friday, 7am - 10pm
Saturday to Sunday, 7am - 3.30pm

Provides 10 chairs for chronic haemodialysis renal service with ability to in-reach to Griffith Base Hospital. Home dialysis is also provided in a 2 Chair Training Unit.

Opening hours:

Monday to Saturday, 7am - 3.30pm

Provides 9 chairs for chronic haemodialysis satellite renal service in partnership with Royal Melbourne Hospital.

Opening hours:

Monday, Wednesday and Friday, 7am - 3.30pm

Provides 4 chairs for chronic haemodialysis satellite renal service.

A self-care unit is also located at Young where those who are suitable for home dialysis can undertake their own dialysis in the unit.

Holiday haemodialysis is available but will depend on available chairs at all Murrumbidgee LHD Renal Units.

Contact the specific renal unit to discuss and start an application. At least 6 weeks notice is required for requests.

Service contacts

Key contacts