Renal: Chronic Kidney Disease

• Basics: What is CKD? | Staging and eGFR | Causes of CKD | Assessing a New Patient | Monitoring and Progression Risk | When to Refer
• Slowing progression: Blood Pressure | ACE Inhibitors and ARBs | SGLT2 Inhibitors | Finerenone | Cardiovascular Risk | Renovascular Disease
• Complications: Anaemia of CKD | Bone and Mineral Disease | Acidosis and Potassium | Prescribing in CKD | Diet, Lifestyle and Vaccines | CKD and Pregnancy | Planning for Kidney Failure | Conservative Kidney Management
• Revision: Drug Reference Table | Spot the Diagnosis | Exam-style Scenarios | Key Points | Guidelines and Further Reading

🫘 Chronic kidney disease (CKD) affects about 1 in 10 adults in the UK. Most people never need dialysis — they are far more likely to die from cardiovascular disease. Care is mostly in general practice. The job is to find it (eGFR and urine ACR), slow it down (BP, ACE inhibitors or ARBs, SGLT2 inhibitors), reduce cardiovascular risk, manage complications, and refer the right patients in time.
Your four questions for every patient: What are the eGFR and ACR — and is this really chronic (over 3 months)? What is the cause? How fast is it progressing (KFRE)? Is everything in place to slow it and protect the heart?

What is CKD?

Definition (KDIGO, NICE NG203): Abnormal kidney structure or function, present for more than 3 months, with implications for health. This means either:

• eGFR under 60 mL/min/1.73 m², or
• Markers of kidney damage, such as:
  • Albuminuria — urine albumin:creatinine ratio (ACR) of 3 mg/mmol or more.
  • Haematuria of kidney origin.
  • Structural abnormalities on imaging (e.g. polycystic kidneys, scarring).
  • Abnormal biopsy; tubular disorders; a kidney transplant.

• Confirm chronicity — repeat eGFR within 2 weeks if a single low result (to rule out AKI), and confirm a reduced eGFR or raised ACR over 3 months.
• Who to test (NICE) — people with:
  • Diabetes; hypertension.
  • Cardiovascular disease.
  • Previous AKI.
  • Structural renal tract disease, stones, prostatic enlargement.
  • Multisystem disease that can affect the kidneys (e.g. lupus).
  • Family history of kidney failure or hereditary kidney disease.
  • Gout.
  • Long-term nephrotoxic drugs (lithium, ciclosporin, NSAIDs).
  • Incidental haematuria.

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Staging and eGFR

CKD is staged by both eGFR (G) and ACR (A) — e.g. "CKD G3a A2". Risk rises with each.

• eGFR — NICE recommends the CKD-EPI creatinine equation, without an adjustment for ethnicity.
• eGFR is less accurate:
  • At extremes of muscle mass (bodybuilders, amputees, frailty).
  • After a meat meal (avoid eating meat in the 12 hours before the test).
  • In pregnancy.
  • During AKI (not in a steady state).
  • With drugs that block creatinine secretion (trimethoprim, cimetidine).
• Cystatin C — an alternative marker not affected by muscle mass. Use it to confirm the diagnosis when eGFR is 45–59 with ACR under 3 (NICE), or when muscle mass is unusual.
• ACR — use an early-morning urine sample if possible; repeat if 3–70 mg/mmol to confirm. ACR is more sensitive than the protein:creatinine ratio (PCR) for low levels.
• ACR over 30 roughly equals protein of 0.5 g/day; ACR over 220 or PCR over 300 suggests nephrotic-range proteinuria (about 3 g/day).

💡 Clinical Pearl: A healthy 85-year-old with eGFR 52 and ACR under 3 has a very low risk of kidney failure. Albuminuria matters as much as eGFR — it predicts both progression and cardiovascular death.

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Causes of CKD

• Diabetic kidney disease — the commonest cause of kidney failure in the UK (about 30%).
• Hypertension and vascular disease (including renovascular disease).
• Glomerulonephritis — IgA nephropathy, membranous nephropathy, FSGS, lupus (see the Glomerular Disease chapter).
• Polycystic kidney disease (ADPKD) and other inherited diseases (Alport syndrome).
• Reflux nephropathy and recurrent pyelonephritis; chronic obstruction.
• Drugs — lithium, NSAIDs, calcineurin inhibitors, PPIs (via interstitial nephritis).
• Myeloma and amyloidosis.
• Chronic interstitial nephritis; stones.
• Unknown — common, especially in older people with small kidneys.

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Assessing a New Patient

• History:
  • Diabetes, hypertension, vascular disease.
  • Drug history (NSAIDs, lithium, PPIs).
  • Urinary symptoms, stones, childhood UTIs.
  • Systemic symptoms (rash, joint pain, weight loss).
  • Family history of kidney disease.
  • Previous creatinine results (to judge the rate of change).
• Examination: BP; fluid status; palpable kidneys (polycystic disease), bladder; renal bruits; signs of vascular disease.
• Tests:
  • U&E, eGFR; urine ACR.
  • Urine dipstick for blood — persistent haematuria with proteinuria suggests glomerular disease.
  • FBC (anaemia); calcium, phosphate, PTH, vitamin D (if G4–5).
  • HbA1c; lipids.
  • Bicarbonate.
  • Renal ultrasound (NICE) if: accelerated progression, visible or persistent invisible haematuria, symptoms of obstruction, family history of polycystic kidney disease (over age 20), eGFR under 30, or being considered for biopsy.
  • Myeloma screen (serum free light chains, protein electrophoresis) if unexplained, especially over 50 with anaemia, high calcium or back pain.
  • Autoimmune screen and complement if glomerular disease is suspected.
• Small kidneys (under 9 cm) on ultrasound suggest long-standing CKD. Exceptions where kidneys may be normal-sized or large: diabetes, polycystic disease, amyloid, HIV, myeloma.

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Monitoring and Progression Risk

• How often to check eGFR and ACR — at least yearly; more often with higher stages (e.g. 2–3 times a year in G3b A2, up to 4 or more times a year in G4–5). NICE has a "heat map" table.
• Accelerated progression (NICE):
  • A sustained fall in eGFR of 25% or more with a change in category within 12 months, or
  • A sustained fall of 15 mL/min/1.73 m² or more per year.
• Kidney Failure Risk Equation (KFRE):
  • Uses age, sex, eGFR and ACR to estimate the 5-year risk of needing dialysis or a transplant.
  • NICE recommends using it for adults with CKD G3a–G5.
  • 5-year risk over 5% = refer to nephrology.
  • Often reported automatically by labs.
• Risk factors for progression:
  • Albuminuria (the strongest).
  • High BP.
  • Poor diabetes control.
  • Smoking; obesity.
  • Repeated AKI.
  • NSAID use.
  • Black ethnicity (e.g. APOL1 gene variants).
  • Urinary obstruction.

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When to Refer

Refer to nephrology (NICE NG203) if:

• 5-year KFRE risk over 5%.
• ACR 70 mg/mmol or more — unless it is known to be caused by diabetes and is already treated appropriately.
• ACR 30 or more with haematuria.
• Accelerated progression (see above).
• Poorly controlled hypertension despite at least 4 antihypertensive drugs at therapeutic doses.
• Known or suspected rare or genetic causes of CKD.
• Suspected renal artery stenosis.

Other reasons to discuss:

• eGFR under 30 (many units accept referral; to plan for kidney failure).
• Complications that are hard to manage (anaemia, potassium, bone disease).
• Uncertainty about the cause.

Don't need referral just because of age-related, stable G3a with no albuminuria.

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Blood Pressure

Targets (NICE NG203, clinic BP):

• ACR under 70 mg/mmol — systolic 120–139 and diastolic under 90.
• ACR 70 mg/mmol or more — systolic 120–129 and diastolic under 80.
• KDIGO suggests a systolic under 120 (standardised measurement) if tolerated — tighter than NICE.
• Relax targets in frailty and postural hypotension.

Drug choice:

• ACE inhibitor or ARB first if there is albuminuria (see below) or diabetes.
• Otherwise follow the NICE hypertension pathway (see the Hypertension chapter).
• Add-ons: Calcium channel blocker; loop diuretic (thiazides work less well when eGFR is under 30, though chlorthalidone still helps); spironolactone (watch potassium); alpha- or beta-blockers.
• Salt restriction (under 6 g/day) makes ACE inhibitors and diuretics work much better.

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ACE Inhibitors and ARBs

Why: They lower pressure inside the glomerulus and reduce proteinuria, slowing progression.

Who should have one (NICE NG203), titrated to the highest licensed dose tolerated:

• Diabetes and ACR over 3 mg/mmol.
• Hypertension and ACR over 30 mg/mmol.
• ACR 70 mg/mmol or more — regardless of diabetes or hypertension.

Safety checks:

• Check potassium and eGFR before starting, and 1–2 weeks after starting and after each dose increase.
• Don't start if potassium is over 5.0 mmol/L (address the cause first).
• Stop if potassium rises to 6.0 mmol/L or more despite other measures (or consider a potassium binder to keep the drug going).
• Acceptable creatinine rise:
  • A fall in eGFR of under 25% (or creatinine rise under 30%) is expected — keep going.
  • 25% or more — look for other causes (dehydration, NSAIDs, renal artery stenosis); reduce or stop if no other cause.
• Don't combine an ACE inhibitor with an ARB (more AKI and hyperkalaemia, no benefit).
• Sick day rules — pause during dehydrating illness.
• Avoid in pregnancy (teratogenic) — advise women of childbearing age.

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SGLT2 Inhibitors

Why: They slow loss of kidney function, reduce albuminuria, and lower the risk of heart failure and cardiovascular death — in people with or without diabetes.

• Type 2 diabetes with CKD (NICE NG28):
  • Offer an SGLT2 inhibitor if ACR is over 30 mg/mmol and the patient is on an ACE inhibitor or ARB (if eGFR is high enough to start).
  • Consider if ACR is 3–30 mg/mmol.
• CKD with or without diabetes (NICE technology appraisals, added on to optimised ACE inhibitor or ARB unless not tolerated):
  • Dapagliflozin 10 mg daily (TA775) — eGFR 25–75, plus either type 2 diabetes or ACR 22.6 mg/mmol or more.
  • Empagliflozin 10 mg daily (TA942) — eGFR 20–45, or eGFR 45–90 with ACR 22.6 or more or type 2 diabetes.
• What to expect:
  • A small, early dip in eGFR (up to about 10–30%) — expected and not a reason to stop.
  • Can usually be continued until dialysis once started.
  • Glucose-lowering effect fades at low eGFR, but kidney and heart benefits remain.
• Side effects and safety:
  • Genital fungal infections (thrush) — advise genital hygiene.
  • Euglycaemic diabetic ketoacidosis — in diabetes; stop during acute illness, before surgery, and when fasting (sick day rules).
  • Volume depletion — consider reducing diuretics.
  • Fournier's gangrene (rare).
  • Not licensed for CKD in type 1 diabetes, polycystic kidney disease, or immunosuppression for kidney disease (excluded from trials).

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Finerenone

• What it is: A non-steroidal mineralocorticoid receptor antagonist — reduces inflammation and scarring in the kidney and heart.
• NICE TA877 — an add-on for CKD stage 3–4 with albuminuria in type 2 diabetes:
  • eGFR 25 or more.
  • Already on the highest tolerated ACE inhibitor or ARB, and an SGLT2 inhibitor (unless unsuitable).
• Dose: 10 mg or 20 mg daily depending on eGFR; adjust by potassium.
• Main risk: hyperkalaemia — don't start if potassium is over 5.0; check potassium at 4 weeks and regularly after.
• Lower hyperkalaemia risk than spironolactone, and less gynaecomastia.

💡 Clinical Pearl: Modern diabetic kidney disease treatment has "four pillars": ACE inhibitor or ARB, SGLT2 inhibitor, finerenone, and a GLP-1 receptor agonist (semaglutide reduced kidney outcomes in the FLOW trial) — on top of BP, glucose and lipid control.

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Cardiovascular Risk

People with CKD are much more likely to die of cardiovascular disease than to reach dialysis.

• Statins (NICE):
  • Offer atorvastatin 20 mg daily for primary or secondary prevention to all adults with CKD (QRISK isn't needed — it underestimates risk in CKD).
  • Increase the dose if non-HDL cholesterol falls by less than 40% and eGFR is 30 or more; discuss with nephrology before higher doses if eGFR is under 30.
• Antiplatelets — for secondary prevention (aspirin or clopidogrel); be aware of the higher bleeding risk in CKD.
• Stop smoking; weight management; exercise.
• BP and diabetes control.
• SGLT2 inhibitors reduce heart failure admissions.
• Vascular calcification and left ventricular hypertrophy are common in advanced CKD.
• Atrial fibrillation — anticoagulate as usual; DOAC doses depend on creatinine clearance (apixaban is often preferred in advanced CKD).

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Renovascular Disease

• Atherosclerotic renal artery stenosis — older smokers with vascular disease:
  • Clues:
    • Creatinine rise of over 30% after starting an ACE inhibitor or ARB.
    • Flash pulmonary oedema (sudden, recurrent).
    • Resistant hypertension.
    • Kidneys of unequal size (over 1.5 cm difference).
    • Abdominal bruit.
    • Low potassium (from high aldosterone).
  • Imaging: Doppler ultrasound, CT or MR angiography.
  • Treatment: Usually medical — statin, antiplatelet, BP control, stop smoking. Stenting didn't improve outcomes in trials (ASTRAL, CORAL) and is reserved for flash pulmonary oedema, rapidly declining function, or uncontrollable BP.
• Fibromuscular dysplasia — young women with hypertension:
  • "String of beads" appearance on angiography.
  • Responds well to angioplasty (without stenting).
  • Screen for other arterial involvement (carotid, aneurysms).
• Hypertensive nephrosclerosis — long-standing hypertension causing small kidneys with mild proteinuria.

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Anaemia of CKD

• Why it happens:
  • Less erythropoietin (EPO) made by the kidney.
  • Iron deficiency — reduced absorption, blood loss, raised hepcidin (inflammation blocks iron release).
  • Shorter red cell lifespan.
• Usually appears from G3b onwards and becomes common in G4–5.
• Investigate when Hb is 110 g/L or less or there are symptoms:
  • Normocytic, normochromic anaemia.
  • Exclude other causes — B12, folate, GI blood loss (endoscopy if indicated), myeloma.
  • Iron status — ferritin (falsely raised by inflammation), transferrin saturation (TSAT), or % hypochromic red cells.
• Treatment (NICE NG203):
  • Iron first — aim for ferritin over 100 µg/L and TSAT over 20% before and during ESA treatment.
    • Oral iron may be tried in non-dialysis CKD.
    • IV iron (e.g. ferric carboxymaltose, iron sucrose, ferric derisomaltose) works better, and is standard in haemodialysis.
  • Erythropoiesis-stimulating agents (ESAs) — e.g. epoetin, darbepoetin, methoxy polyethylene glycol-epoetin beta:
    • Given subcutaneously (or IV on dialysis).
    • Target Hb 100–120 g/L — aiming higher increases stroke, hypertension, and access thrombosis (TREAT and CHOIR trials).
    • Side effects: hypertension, seizures, thrombosis; rare pure red cell aplasia.
    • Poor response — check iron, bleeding, infection, hyperparathyroidism, B12 and folate, aluminium, adherence.
  • HIF-prolyl hydroxylase inhibitors — roxadustat (oral; NICE TA807 for symptomatic anaemia in non-dialysis CKD) — boost the body's own EPO.
  • Blood transfusion — avoid where possible in transplant candidates (causes antibodies that make matching harder).

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Bone and Mineral Disease

CKD–mineral and bone disorder (CKD-MBD) — from about G3b–G4 onwards:

• What happens:
  • Kidneys can't excrete phosphate → phosphate rises.
  • Kidneys make less active vitamin D (1-alpha hydroxylation) → less calcium absorbed → calcium falls.
  • Both drive PTH up — secondary hyperparathyroidism.
  • FGF-23 rises early.
• Consequences:
  • Renal osteodystrophy — bone pain, fractures (osteitis fibrosa, adynamic bone disease, osteomalacia).
  • Vascular calcification — cardiovascular disease.
  • Calciphylaxis (calcific uraemic arteriolopathy) — very painful skin ulcers with black eschar; high mortality; mostly in dialysis patients.
  • Itch.
• Tertiary hyperparathyroidism — after long-standing secondary disease, the parathyroids become autonomous: high calcium with very high PTH (often after a transplant).
• Monitoring: Calcium, phosphate, PTH, alkaline phosphatase, vitamin D (from G4, or earlier if indicated).
• Treatment:
  • Diet — limit phosphate (processed foods, cola, dairy) with dietitian advice.
  • Phosphate binders (taken with meals):
    • Calcium acetate — NICE first line.
    • Sevelamer — non-calcium; if calcium is high or there is vascular calcification.
    • Lanthanum; sucroferric oxyhydroxide; calcium carbonate.
  • Vitamin D:
    • Colecalciferol or ergocalciferol — for vitamin D deficiency.
    • Alfacalcidol or calcitriol (active vitamin D) — for secondary hyperparathyroidism in G4–5 (watch for high calcium and phosphate).
  • Cinacalcet (oral) or etelcalcetide (IV on dialysis) — calcimimetics that lower PTH, mainly in dialysis patients.
  • Parathyroidectomy — for severe or tertiary hyperparathyroidism.
  • Osteoporosis drugs — use with caution in G4–5; bisphosphonates are usually avoided if eGFR is under 30–35; specialist advice (adynamic bone disease risk; denosumab can cause severe low calcium).

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Acidosis and Potassium

• Metabolic acidosis:
  • The kidneys can't excrete acid; worsens bone disease and muscle wasting, and may speed CKD progression.
  • Consider oral sodium bicarbonate if eGFR under 30 and serum bicarbonate under 20 mmol/L (NICE).
  • Dose e.g. 500 mg–1 g two to three times daily; watch for fluid retention and high BP.
• Hyperkalaemia:
  • Causes — low eGFR, ACE inhibitors and ARBs, spironolactone, finerenone, trimethoprim, NSAIDs, diet, acidosis, constipation.
  • Management:
    • Review drugs.
    • Low-potassium diet (dietitian) — but avoid unnecessary restriction of fruit and vegetables.
    • Treat acidosis; treat constipation.
    • Loop diuretic if fluid-overloaded.
    • Potassium binders — sodium zirconium cyclosilicate (TA599) or patiromer (TA623) — for persistent potassium of 6.0 or more, to allow an ACE inhibitor or ARB to continue.
  • Acute hyperkalaemia — see the AKI and Renal Emergencies chapter.
• Hyperuricaemia and gout — common; allopurinol (dose-adjust) or febuxostat; don't treat raised urate without gout to protect the kidneys (no benefit in trials).

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Prescribing in CKD

• Use creatinine clearance (Cockcroft–Gault) for drugs with a narrow therapeutic range (DOACs, aminoglycosides, vancomycin, digoxin, lithium) and in people at extremes of body weight; eGFR for most others.
• Avoid where possible:
  • NSAIDs (including long-term over-the-counter use).
  • Nitrofurantoin if eGFR is under 45 (less effective, more toxic — short courses can be used with caution 30–44).
  • Metformin if eGFR under 30.
  • Bisphosphonates if eGFR under 30–35.
  • Gadolinium (older agents) in severe CKD.
• Reduce dose or monitor closely:
  • Metformin — review the dose if eGFR is under 45; stop if under 30.
  • Sulfonylureas (gliclazide preferred) and insulin — hypoglycaemia risk.
  • DPP-4 inhibitors — dose-adjust (linagliptin needs no adjustment).
  • Opioids — avoid morphine and codeine in advanced CKD (metabolites accumulate); oxycodone with caution; fentanyl, alfentanil and buprenorphine are safer.
  • Gabapentin and pregabalin — drowsiness and falls.
  • Antibiotics — many need dose changes (e.g. co-amoxiclav, clarithromycin, aciclovir, co-trimoxazole).
  • Allopurinol; colchicine (toxicity).
  • Digoxin and lithium — levels.
  • LMWH — dose-adjust or use unfractionated heparin in severe CKD.
  • DOACs — dose by creatinine clearance.
  • Baclofen — encephalopathy at low eGFR.
• Check the BNF or Renal Drug Database for every new drug in G4–5.

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Diet, Lifestyle and Vaccines

• Salt — under 6 g/day (5 g/day KDIGO).
• Protein — avoid very high-protein diets; don't restrict protein to very low levels without dietitian support (risk of malnutrition).
• Potassium and phosphate — limit only if levels are high (dietitian).
• Fluids — no fixed rule for most; restrict only if overloaded or on dialysis.
• Weight loss, exercise, stop smoking.
• Avoid over-the-counter NSAIDs and herbal remedies.
• Vaccines:
  • Influenza yearly.
  • Pneumococcal (CKD G4–5, nephrotic syndrome, transplant).
  • COVID-19 as per current programme.
  • Hepatitis B — for those likely to need dialysis or a transplant.
  • Shingles (as per programme; non-live vaccine if immunosuppressed).

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CKD and Pregnancy

• Higher risks — pre-eclampsia, preterm birth, growth restriction, and worsening of kidney function (especially if creatinine is high, or with proteinuria and hypertension).
• Pre-pregnancy counselling — ideally with stable disease for at least 6 months.
• Stop ACE inhibitors, ARBs, SGLT2 inhibitors, finerenone and statins before conception or as soon as pregnancy is confirmed. Switch BP drugs to labetalol, nifedipine or methyldopa.
• Aspirin 75–150 mg from 12 weeks to reduce pre-eclampsia risk.
• Mycophenolate is teratogenic — switch to azathioprine well before conception.
• Joint care between obstetrics and nephrology.
• See the Tubular, Inherited and Stones chapter for kidney problems in pregnancy.

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Planning for Kidney Failure

• Start planning when the KFRE 2-year risk is high or eGFR is around 20 and falling — usually about a year before kidney failure.
• Education programme — explain options so the patient can choose:
  • Pre-emptive kidney transplant (before dialysis) — the best outcomes. Listing in the UK when eGFR is under 15 and expected to need dialysis within 6 months; living donor work-up earlier.
  • Peritoneal dialysis (home).
  • Home haemodialysis.
  • Hospital or satellite haemodialysis.
  • Conservative kidney management (no dialysis).
• Dialysis access — an arteriovenous fistula needs 6–12 weeks or more to mature; create it months before dialysis.
• Protect arm veins — avoid cannulas and blood tests in the non-dominant arm veins (use the back of the hand) and avoid PICC lines in people likely to need a fistula.
• When to start dialysis — based on symptoms (uraemia, fluid overload, potassium, acidosis, malnutrition), usually when eGFR is around 5–10, not a fixed number (IDEAL trial — early start had no benefit).
• Symptoms of uraemia:
  • Tiredness, poor appetite, nausea, vomiting, weight loss.
  • Itch.
  • Restless legs; muscle cramps.
  • Breathlessness, oedema.
  • Poor concentration; confusion (late).
  • Pericarditis (late).

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Conservative Kidney Management

• What it is: Active, planned care for kidney failure without dialysis — focused on symptoms, quality of life and advance care planning. It isn't "no treatment".
• Who chooses it:
  • Often older, frail people with several other conditions.
  • In this group, dialysis may not extend life much, and involves many hours of treatment and hospital visits.
• What it includes:
  • Continue treatments that help — BP, anaemia, fluid, acidosis, potassium.
  • Symptom control:
    • Itch — emollients; gabapentin (low dose); sertraline.
    • Nausea — low-dose haloperidol; avoid metoclopramide build-up.
    • Restless legs — check iron; low-dose dopamine agonists, gabapentin.
    • Breathlessness and fluid — diuretics.
    • Pain — renally safe opioids (fentanyl, alfentanil, buprenorphine).
  • Advance care planning; preferred place of death; palliative care involvement.
• Stopping dialysis — a person's right; death usually follows within 1–2 weeks. Manage symptoms with renally safe drugs (see the End-of-Life Care chapter).

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Drug Reference Table

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Spot the Diagnosis

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Exam-style Scenarios

1. A 62-year-old with type 2 diabetes has eGFR 41 and ACR 58 mg/mmol (confirmed). She takes metformin 1 g twice daily and amlodipine. BP 148/88.
Answer: Diabetic kidney disease, CKD G3b A3.

• Start an ACE inhibitor or ARB, titrate to maximum; check K and eGFR at 1–2 weeks.
• Add an SGLT2 inhibitor; consider finerenone if albuminuria persists.
• Reduce metformin (eGFR under 45); atorvastatin 20 mg; BP target under 140/90 (under 130/80 if ACR 70 or more).
• Calculate KFRE; sick day rules.

2. A 70-year-old's creatinine rises from 110 to 160 µmol/L after starting ramipril. He has peripheral vascular disease.
Answer: Over 30% rise — suspect renal artery stenosis.

• Stop ramipril; exclude dehydration and NSAIDs.
• Renal Doppler or CT/MR angiography.
• Medical treatment (statin, antiplatelet, BP control); stent only for flash pulmonary oedema or rapid decline.

3. A man on haemodialysis has Hb 89 g/L despite epoetin. Ferritin 80, TSAT 12%.
Answer: ESA resistance from iron deficiency.

• IV iron to ferritin over 100 and TSAT over 20%.
• Look for blood loss, infection, hyperparathyroidism, B12/folate deficiency.
• Target Hb 100–120 g/L.

4. CKD G4: calcium 2.10, phosphate 2.1, PTH 45 pmol/L, vitamin D low.
Answer: CKD-mineral and bone disorder with secondary hyperparathyroidism.

• Dietary phosphate advice; calcium acetate with meals.
• Colecalciferol for deficiency; alfacalcidol if PTH stays high.
• Monitor calcium, phosphate and PTH.

5. An 88-year-old with heart failure, dementia and CKD G5 (eGFR 9) is breathless and itchy. Her family asks about dialysis.
Answer: Discuss conservative kidney management.

• Explain the limited benefit of dialysis in frailty; shared decision-making; advance care planning.
• Diuretics for fluid; emollients and low-dose gabapentin for itch; treat anaemia and acidosis.
• Involve palliative care; renally safe drugs.

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Key Points

• CKD = eGFR under 60 or markers of damage (ACR 3 or more) for over 3 months; stage by both G and A.
• Always measure ACR as well as eGFR — albuminuria drives progression and cardiovascular risk.
• Use CKD-EPI eGFR without ethnicity adjustment; cystatin C if muscle mass is unusual.
• Refer if KFRE 5-year risk over 5%, ACR 70 or more, ACR 30 or more with haematuria, accelerated decline, resistant hypertension, or suspected genetic or renovascular disease.
• ACE inhibitor or ARB at maximum tolerated dose for albuminuria; accept an eGFR fall under 25%.
• SGLT2 inhibitors slow CKD with or without diabetes; finerenone adds benefit in type 2 diabetes.
• Offer atorvastatin 20 mg to all adults with CKD.
• Anaemia: replace iron first; ESA target Hb 100–120 g/L.
• CKD-MBD: phosphate binders, vitamin D, calcimimetics; watch for calciphylaxis and tertiary hyperparathyroidism.
• Oral bicarbonate if eGFR under 30 and bicarbonate under 20.
• Avoid NSAIDs; dose-adjust renally cleared drugs; use fentanyl or alfentanil rather than morphine in advanced CKD.
• Plan for kidney failure early: education, pre-emptive transplant, fistula, vein preservation.
• Conservative kidney management is a valid, active choice for frail older people.

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Guidelines and Further Reading

• NICE NG203: Chronic kidney disease — assessment and management
• NICE NG28: Type 2 diabetes in adults (SGLT2 inhibitors in CKD)
• NICE TA775 (dapagliflozin), TA942 (empagliflozin), TA877 (finerenone), TA807 (roxadustat), TA599 (sodium zirconium cyclosilicate), TA623 (patiromer)
• NICE NG238: Cardiovascular disease — risk assessment and reduction, including lipid modification
• KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of CKD
• UK Kidney Association: clinical practice guidelines (anaemia, CKD-MBD, planning, SGLT2 inhibition)
• BNF and Renal Drug Database — for current doses and renal dose adjustments

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