PassFinals
Renal & Urology

Chronic kidney disease

Diagnose CKD by persistent reduced GFR or a marker of kidney damage, stage it with eGFR and ACR, then reduce cardiovascular and kidney-failure risk through blood-pressure control, renoprotective treatment, monitoring and timely renal referral.

In a nutshell

CKD is persistent reduction in kidney function or a persistent marker of damage. Stage with eGFR and urine ACR, control BP to the ACR-specific target, use ACE inhibitor/ARB and eligible SGLT2 therapy, calculate KFRE, monitor progression and refer when risk or red flags justify renal input.

Classic presentation

An asymptomatic patient with persistent low eGFR or albuminuria, often in diabetes or hypertension, or a patient with progressive renal decline, resistant BP or complications of advanced CKD.

Key points

  • Confirm chronicity or a persistent marker of damage and exclude AKI before labelling CKD.
  • Stage with both G category and ACR category; ACR 3, 30 and 70 mg/mmol are important treatment and referral thresholds (see NICE NG203; see BNF for medicine dosing).
  • For adults, BP target is below 140/90 when ACR is below 70 mg/mmol and below 130/80 when ACR is 70 mg/mmol or more, with individualisation for frailty and multimorbidity (see NICE NG203; see BNF for medicine dosing).
  • Offer ACE inhibitor or ARB for hypertension with ACR above 30, and for diabetes with ACR 3 or more; titrate to the highest tolerated licensed dose and monitor creatinine and potassium.
  • Use current NICE TA1075/TA942 criteria for SGLT2 inhibitors and TA877 criteria for finerenone; technology-appraisal eligibility changes over time.
  • Refer adults for KFRE five-year kidney-failure risk above 5%, ACR 70 or more, ACR over 30 with haematuria, rapid eGFR decline or resistant hypertension.
  • An unexplained creatinine rise of 30% or more after ACE inhibitor/ARB requires investigation for volume depletion, NSAIDs and other causes before dose reduction or stopping.

First-line investigation

Repeat eGFR and urine ACR to confirm chronicity, classify G/A risk and check blood pressure, urinalysis, electrolytes and relevant CKD complications.

Management

Exclude AKI and urgent complications

  • Review change from baseline, urine output, potassium, acid-base status, fluid status and symptoms; send acute deterioration through the AKI or emergency pathway.9,1

Stage with eGFR and ACR

  • Confirm persistence, record G/A categories, assess haematuria and calculate KFRE in adults so monitoring and referral reflect total risk.1,2

Treat BP, albuminuria and cardiovascular risk

  • Use the ACR-specific BP target, titrate ACE inhibitor/ARB when indicated, add eligible SGLT2 or finerenone therapy and monitor renal function, potassium and adverse effects.1,5,6,7,3,4

Refer progressive or high-risk disease

  • Refer for KFRE risk above 5%, ACR 70 or more, ACR over 30 with haematuria, rapid decline, refractory BP, suspected systemic renal disease or obstruction.1,2

Monitor and plan advanced kidney care

  • Set a dated eGFR/ACR monitoring plan, review complications and medicine safety, and discuss conservative care, dialysis or transplant planning before kidney failure when appropriate.1,2,12

Exam traps

  • eGFR 60 to 89 alone is not CKD without another marker of kidney damage.
  • Use ACR rather than an ordinary urine reagent strip to detect and quantify albuminuria.
  • Do not combine an ACE inhibitor with an ARB for CKD proteinuria.
  • A small early creatinine rise after renin-angiotensin blockade is not automatically a reason to stop; use the 30%/25% thresholds and investigate reversible causes.
  • Do not use the outdated automatic eGFR below 30 referral rule in place of current KFRE and ACR criteria.
  • Do not use a stable CKD eGFR to interpret rapidly changing AKI.
  • SGLT2 eligibility is determined by the current NICE technology appraisal, eGFR, ACR and diabetes status, not by a single universal CKD threshold.

Illustrations

CKD G and A staging gridColour-coded grid combining eGFR categories G1 to G5 with ACR categories A1 to A3 to show increasing risk.PassFinals · original
ACR-led treatment pathwayFlow diagram linking ACR thresholds to BP targets, ACE inhibitor or ARB use, SGLT2 eligibility and nephrology referral.PassFinals · original
CKD progression and renal referralTimeline showing stable monitoring, progression markers, KFRE risk calculation, renal referral and advance kidney-care planning.PassFinals · original

Key sources

  1. NICE NG203: Chronic kidney disease, assessment and management (NG203 recommendations, current with SGLT2 technology-appraisal links)
  2. UK Kidney Association: UK eCKD Guide (Current professional CKD staging, KFRE and referral resources)
  3. BNF: Ramipril (BNF ACE-inhibitor monograph for CKD prescribing and monitoring)
  4. BNF: Losartan potassium (BNF ARB monograph for CKD prescribing and monitoring)
  5. NICE TA1075: Dapagliflozin for treating chronic kidney disease (TA1075, published 2 July 2025; replaces TA775)
  6. NICE TA942: Empagliflozin for treating chronic kidney disease (TA942 current NICE technology appraisal)
  7. NICE TA877: Finerenone for treating CKD in type 2 diabetes (TA877, stage 3/4 CKD with albuminuria associated with type 2 diabetes)
  8. NICE NG28: Type 2 diabetes, initial medicines (NG28 current CKD-related SGLT2 recommendations)
  9. NICE NG148: Acute kidney injury (NG148 for excluding and managing acute changes in renal function)
  10. BNF: Dapagliflozin (BNF SGLT2 inhibitor monograph for renal dosing and safety)
  11. BNF: Empagliflozin (BNF SGLT2 inhibitor monograph for renal dosing and safety)
  12. BNF: Ibuprofen (BNF NSAID monograph for renal cautions)
  13. NICE NG203: Update information (NG203 update history including 2021 proteinuria and treatment amendments)

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.