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  3. Chronic Kidney Disease (CKD)

Chronic Kidney Disease (CKD)

NICE guideline [NG203] Chronic kidney disease: assessment and management. Last updated: Nov 2021.

Diagnosis Guidelines

CKD testing is recommended in adults with any of the following:
  • Diabetes
  • Hypertension
  • Cardiovascular disease (ischaemic heart disease, chronic heart failure, peripheral vascular disease, cerebral vascular disease)
  • Previous AKIAcute kidney injury
  • Structural renal tract disease / recurrent renal calculi / prostatic hypertrophy
  • Multi-system disease with potential kidney involvement (e.g. SLESystemic lupus erythematosus)
  • Hereditary kidney disease / family history of end-stage renal disease
  • Incidental detection of proteinuria or haematuria
  • Gout

Test for CKD with eGFR (creatinine) and ACRAlbumin:creatinine ratio


Monitor CKD with the same tests
 

NICE recommends using CKD-EPI equation to calculate eGFR in adults, which takes the following into consideration:

  • Serum creatinine
  • Sex
  • Age

Factors affecting eGFR interpretation:
 
Factors that cause falsely ↑ creatinine → falsely low eGFR (underestimated) Factors that cause falsely ↓ creatinine → falsely high eGFR (overestimated)
  • High muscle mass (e.g. bodybuilders)
  • Recent meat intake (<12 hours before blood test)
  • Delay transport to the lab
  • Trimethoprim (blocks tubular creatinine secretion)
  • Low muscle mass (e.g. amputees, cachexia)
  • Pregnancy (↑ true GFR as part of physiological change in pregnancy)
  • Severe liver impairment
 

NICE recommends classifying CKD using BOTH eGFR and ACRAlbumin: creatinine ratio
 
  A1 (ACR <3) A2 (ACR 3-30) A3 (ACR >30)
G1 (eGFR ≥90) Low risk

*No CKD if no other markers of kidney damage		 Moderate risk High risk
G2 (eGFR 60-89) Low risk

*No CKD if no other markers of kidney damage		 Moderate risk High risk
G3a (eGFR 45-59) Moderate risk High risk Very high risk
G3b (eGFR 30-44) High risk Very high risk Very high risk
G4 (eGFR 15-29) Very high risk Very high risk Very high risk
G5 (eGFR <15) Very high risk Very high risk Very high risk


CKD staging based on eGFR solely (still commonly used and common in exams):
 

CKD stage Criteria
1 eGFR >90 + marker of kidney damage
2 eGFR 60-89 + marker of kidney damage
3a eGFR 45-59
3b eGFR 30-44
4 eGFR 15-29
5 (end-stage renal disease) eGFR <15
 
 

Note that CKD ≥60 in the absence of other kidney damage markers does NOT constitute CKD. 

Offer renal ultrasound to all adults, if any of the following:
  • Accelerated progression of CKD
  • Visible / persistent invisible haematuria
  • Symptoms of urinary tract obstructions
  • >20 y/o with family history of polycystic kidney disease
  • eGFR <30 (G4 or G5)
  • Renal biopsy needed

1st line test: urine ACRAlbumin:creatinine ratio
  • ≥3 mg/mmol is defined as clinically important proteinuria
  • If initial result is 3-70 mg/mmol → repeat an early morning sample to confirm results
 
 

Do NOT use reagent strips (urine dipsticks) to identify proteinuria.

Urine ACRAlbumin:creatinine ratio is preferred over PCRProtein:creatinine ratio due to greater sensitivity of low levels of proteinuria. PCRProtein:creatinine ratio should only be used as an alternative to ACRAlbumin:creatinine ratio if ACRAlbumin:creatinine ratio is ≥70 mg/mmol

Measuring proteinuria with urine ACRAlbumin:creatinine ratio is indicated in any of the following:
  • Diabetes (type 1 / 2) - all patients
  • Incidental finding of unexplained proteinuria on reagent strip (urine dipstick)
  • Adtuls
    • CKD-range eGFR (<60)
    • No CKD-range eGFR but strong suspicion of CKD
  • Children and young people
    • Serum creatinine level above upper limit of age-appropriate reference range

Use reagent strip (urine dipstick) to test for haematuria
  • Investigate further if 1+ or higher
  • Consider performing 3 tests to differentiate from transient haematuria
  • Do not use urine microscopy to confirm haematuria

Note that isolated haematuria in a woman of reproductive age can just be menstruation. Ensure to exclude that...

Management Guidelines

Assess 5-year risk of needing RRT with the 4-variable Kidney Failure Risk Equation

Refer adults with CKD for specialist assessment if any of the following:
  • 5-year risk of needing RRT >5%
  • ACR ≥70 mg/mmol (unless caused by diabetes and already appropriately treated)
  • ACR ≥30 mg/mmol + haematuria
  • Accelerated progression of CKD
  • Suspected renal artery stenosis
  • Known / suspected rare or genetic cause of CKD

Lifestyle advice is very personalised in CKD, depending on various factors (e.g. polyuric or oligouric, electrolyte levels, fluid status).

Some key lifestyle advice:
  • Regulate protein intake (usually ~0.8g per kg per day)
    • Usually advised by dietitian
    • Do NOT routinely recommend a low-protein diet
  • Limit sodium intake
  • Some situational advice (usually only advised if there is a problem)
    • Fluid restriction
    • Low phosphate diet
    • Low potassium diet

There are 3 main aspects of CKD management
  • Hypertension
  • Proteinuria
  • CVD secondary prevention
 

Treat hypertension as per this article.
 

BP targets in CKD depend on ACRAlbumin:creatinine ratio level:

  • ACRAlbumin:creatinine ratio <70 mg/mmol target: <140/90 mmHg
  • ACRAlbumin:creatinine ratio ≥70 mg/mmol target: <130/80 mmHg 

1st line: ACE inhibitor / ARB
  • Offer if CKD with ACRAlbumin:creatinine ratio >30 mg/mmol (even if there is no hypertension), or
  • if CKD + diabetes (type 1 / 2) with ACRAlbumin:creatinine ratio >3 mg/mmol

2nd line: SGLT-2 inhibitor (dapagliflozin / empagliflozin)
  • Add SGLT-2 inhibitor in addition to ACE inhibitor / ARB if
    • eGFR 20-45, or
    • eGFR 45-90 + T2DM / urine ACRAlbumin:creatinine ratio ≥22.6, or

CKD alone is an indication for statin therapy (primary prevention):
  • 1st line: atorvastatin 20mg

 

NICE recommends atorvastatin 20mg for both primary and secondary prevention in CKD.

CKD Complications

Test and exclude iron deficiency

 

There is no specific test that definitively confirms anaemia of CKD, it is diagnosed by excluding other causes of anaemia in conjunction with clinical context.

Anaemia of CKD is unlikely if eGFR >60, but very likely if eGFR <30.

First, correct any iron deficiency
  • Offer high-dose IV iron for those with stage 5 CKD on haemodialysis

Then, consider erythropoietic stimulating agent therapy (roxadustat / vadadustat)

Hyperphosphataemia is often only seen in CKD stage 4 / 5.
 

Step 1: dietary management and optimise dialysis (if on it)
  • Low phosphate diet
  • Do NOT routinely recommend low-protein diet

Step 2: phosphate binders
  • 1st line: calcium acetate
  • 2nd line: sevelamer carbonate
  • Other: calcium carbonate, sucroferric oxyhydroxide, lanthanum carbonate

References

Author: Adams Lau
Reviewer:
Last edited: 21/08/25