CKD

• Chronic Kidney Disease (CKD)

  Long terms condition - gradual decline in kidney function over a period of time
• Definition - abnormal kidney function and/or structure that has been present for more than three months
• Criteria for CKD


  • eGFR < 60 mL/min/1.73m2 (on at least two occasions, 90 days apart)
  • One or more markers of kidney damage: albuminuria, urine sediment abnormalities, haematuria, electrolyte abnormalities due to tubular disorders, renal histological abnormalities, structural abnormalities detected by imaging, a history of kidney transplantation
• Estimated that 1 in 10 people live with CKD – may often by asymptomatic initially
• Prevalence increases with age
• Black, Asian and minority ethnic communities are five times more likely to develop CKD than other groups
• Those with CKD have a substantially increased mortality risk
• CKD commonly leads to cardiovascular disease and other complications such as anaemia, disordered bone mineral metabolism and calcification of blood vessels
• CKD can result in end-stage kidney failure
• Risk factors for CKD

  • Hypertension
  • Diabetes
  • Increasing age
  • Certain medicines which adversely effect kidney function e.g. chronic NSAID use, Tacrolimus
  • Cardiovascular disease (IHD, heart failure, cerebral vascular disease, peripheral vascular disease)
  • Acute kidney injury (AKI)
  • Family history
  • Smoking
  • African, African-Caribbean or Asian family history (due to higher rate of diabetes/hypertension)
  • Untreated urinary outflow tract obstruction
  • Gout
  • Conditions with potential kidney involvement
• Causes of CKD


  • Conditions associated with intrinsic kidney disease (those that affect the kidney's tissues), such as hypertension, type 1 and type 2 diabetes mellitus, hypercholesterolemia
  • Kidney infections
  • Glomerulonephritis (inflammation of the glomeruli of the kidneys)
  • Medicines that are impactful on the kidneys, such as lithium, calcineurin inhibitors (e.g. ciclosporin or tacrolimus), aminoglycosides, mesalazine
  • Conditions associated with obstructive kidney disease
  • Multisystem diseases that may involve the kidney e.g. systemic lupus erythematosus (SLE)
  • Hereditary history of kidney disease
• Symptoms of CKD


  • Tiredness
  • Trouble concentrating
  • Poor appetite
  • Swollen feet and ankles
  • Puffiness around the eyes, especially in the morning
  • Trouble sleeping
  • Muscle cramping at night
  • Dry, itchy skin
  • The need to urinate more often, especially at night
• Staging and classification of CKD

  Chronic kidney disease is classified using a combination of GFR and albumin:creatinine ratio (ACR)
• An increased ACR and decreased eGFR are both associated with an increased risk of adverse outcomes, and the risks of these are additive
• Management of CKD


  • Prevent or delay the progression of CKD
  • Reduce or prevent the development of complications
  • Manage any complications/symptoms that may develop
  • Reduce the risk of cardiovascular disease
• Blood pressure management in CKD

  • Aim for BP < 140/90 mmHg (unless the patient has significant proteinuria then < 130/80 mmHg is aimed for)
  • If ACR < 30mg/mmol follow NICE guidelines for hypertension plus appropriate tailored lifestyle advice
  • If ACR > 30mg/mmol - start with ACE inhibitor/angiotensin receptor blockers (ARBs)
• ACE inhibitors/ARBs - beneficial effects on proteinuria and slow the progression of CKD
• Renal impairment and diabetes are both associated with an increased risk of adverse outcomes, and the risks of these are additive
• There is no cure for chronic kidney disease (CKD)
• Aims of management of CKD

  • Prevent or delay the progression of CKD
  • Reduce or prevent the development of complications
  • Manage any complications/symptoms that may develop
  • Reduce the risk of cardiovascular disease
• Blood pressure targets in CKD

  Aim for BP < 140/90 mmHg (unless the patient has significant proteinuria then < 130/80 mmHg is aimed for)
• Blood pressure (hypertension) management in CKD

  1. If ACR < 30mg/mmol follow NICE guidelines for hypertension plus appropriate tailored lifestyle advice

  2. If ACR > 30mg/mmol - start with ACE inhibitor/angiotensin receptor blockers (ARBs)

  3. ACE inhibitors/ARBs - beneficial effects on proteinuria and slow the progression of CKD but safety considerations (monitor potassium and renal function)

  4. Many antihypertensives may be difficult to use in CKD (e.g. dihydropyridine calcium-channel blockers can cause ankle swelling, thiazide diuretics ineffective if eGFR < 30 mL/min/1.73m2)

  5. Resistant hypertension can develop that requires many medicines
• NICE recommends that atorvastatin 20 mg daily is offered to patients with CKD and an eGFR of less than 60 mL/min/1.73m2
• Antiplatelet drugs should be used in CKD for the secondary prevention of cardiovascular disease but be aware that there is an increased risk of bleeding in patients with CKD
• Dapagliflozin (SGLT2 inhibitor)


  • Gives cardiovascular and kidney protection in diabetic and non-diabetic CKD
  • Additionally improves glycaemic control in type 2 diabetes
• NICE criteria for recommending dapagliflozin for CKD

  1. It is an add-on to optimised standard care including the highest tolerated licensed dose of angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs), unless these are contraindicated

  2. People have an eGFR of 25 ml/min/1.73 m2 to 75 ml/min/1.73 m2 at the start of treatment

  3. Have type 2 diabetes or have a urine albumin-to-creatinine ratio (uACR) of 22.6 mg/mmol or more
• Tight control of hyperglycaemia in diabetes is also important in preventing or delaying CKD progression
• Vaccinations recommended for people with CKD

  • Flu vaccine
  • Covid vaccine
  • Pneumococcal vaccine
• Anaemia in CKD


  Caused by decreased erythropoietin production (kidney usually produces this) and decrease in the amount of iron absorbed
• Treatment options for anaemia in CKD

  • Erythropoiesis stimulating agents (ESAs)
  • Iron (oral and intravenous)
  • Blood transfusion
• Causes of renal bone disease in CKD

  • Hyperphosphatemia (high levels of phosphate) - as kidney cannot excrete phosphate
  • Hypocalcaemia (low levels of calcium) - cannot absorb calcium from the GI tract due to an inability to activate vitamin D (kidney activates vitamin D)
  • Secondary hyperparathyroidism develops (high PTH levels)
• Treatment options for renal bone disease in CKD

  • Address imbalances of calcium, phosphate, Vitamin D, Parathyroid Hormone (PTH)
  • Restrict dietary phosphate intake
  • Use phosphate-binders
  • Use vitamin D supplementation with activated forms of vitamin D e.g. alfacalcidol
  • Use cinacalcet (oral) or etelcalcetide (intravenous) to lower high PTH levels
• Other issues that can arise in CKD

  • Electrolyte regulation issues (hyperkalaemia, hyperphosphataemia)
  • Fluid retention (may require loop diuretics)
  • Gout (may need colchicine, allopurinol)
  • Acid-base balance issues (may require sodium bicarbonate supplementation)
• Prescribing considerations in CKD

  • Ensure doses of medicines are appropriate for renal function
  • Start low (dose) and go slow when prescribing in CKD
  • Renally cleared drugs with a narrow therapeutic range can be problematic
  • Consider alternative medicines that aren't renally excreted
  • Regularly review medicines to minimise nephrotoxic drugs
  • Some medicines are ineffective in CKD e.g. bendroflumethiazide
  • Avoid medicines that worsen the symptoms of CKD (e.g. NSAIDs)