Chronic Kidney Disease

The answer first

Chronic kidney disease (CKD) is an abnormality of kidney structure or function present for more than three months, with implications for health [1]. Operationally, the KDIGO definition requires any of: eGFR <60 mL/min/1.73 m² for over three months; markers of kidney damage (albuminuria [ACR >3 mg/mmol], urine sediment abnormalities, imaging abnormalities, or kidney transplant); or a kidney biopsy showing chronic disease.

The two clinical questions that dominate CKD management: [1]

1. What is causing the kidney disease, and is it treatable or reversible? Always name the cause — CKD is a syndrome, not a diagnosis.
2. What is the risk of progression to kidney failure, and how do I reduce that risk and the cardiovascular risk that dwarfs it? [1]

The management mandate, in priority order: [1]

1. Identify and treat the underlying cause — and exclude any superimposed acute-on-chronic process.
2. Slow progression with the evidence-based quartet: RAAS blockade for albuminuria, SGLT2 inhibition, blood pressure control, and (in diabetic CKD) finerenone. Reduce proteinuria as a surrogate endpoint.
3. Prevent and manage complications — CKD-MBD, anaemia, acidosis, hyperkalaemia, volume overload, and the dominant risk of cardiovascular disease.
4. Prepare for kidney replacement therapy (KRT) early — at eGFR <30 refer for dialysis education, plan vascular access at eGFR 15-20, and arrange pre-emptive transplant workup. Offer a conservative care pathway for those who will not benefit from dialysis.
5. Minimise iatrogenic harm — dose-adjust every renally cleared drug, avoid nephrotoxins (NSAIDs, gadolinium in severe CKD), and hold the sick-day medications during intercurrent illness. [1]

The single most important exam principle: cardiovascular disease kills more CKD patients than kidney failure does. A stage 3b patient is far more likely to die of an MI than reach dialysis. CKD is a coronary risk equivalent, and management must reflect this. [1]

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References11Show ledgerHide ledger

1. [1]Stevens PE, Levin A Evaluation and management of chronic kidney disease: synopsis of the kidney disease: improving global outcomes 2012 clinical practice guideline Ann Intern Med, 2013.PMID 23732715
2. [2]Inker LA, Eneanya ND, Coresh J, et al. New Creatinine- and Cystatin C-Based Equations to Estimate GFR without Race N Engl J Med, 2021.PMID 34554658
3. [3]Heerspink HJL, Stefánsson BV, Correa-Rotter R, et al. Dapagliflozin in Patients with Chronic Kidney Disease N Engl J Med, 2020.PMID 32970396
4. [4]Herrington WG, Staplin N, Wanner C, et al. Empagliflozin in Patients with Chronic Kidney Disease N Engl J Med, 2023.PMID 36331190
5. [5]Perkovic V, Jardine MJ, Neal B, et al. Canagliflozin and Renal Outcomes in Type 2 Diabetes and Nephropathy N Engl J Med, 2019.PMID 30990260
6. [6]Bakris GL, Agarwal R, Anker SD, et al. Effect of Finerenone on Chronic Kidney Disease Outcomes in Type 2 Diabetes N Engl J Med, 2020.PMID 33264825
7. [7]Brenner BM, Cooper ME, de Zeeuw D, et al. Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy N Engl J Med, 2001.PMID 11565518
8. [8]Wright JT Jr, Williamson JD, Whelton PK, et al. A Randomized Trial of Intensive versus Standard Blood-Pressure Control N Engl J Med, 2015.PMID 26551272
9. [9]Pfeffer MA, Burdmann EA, Chen CY, et al. A trial of darbepoetin alfa in type 2 diabetes and chronic kidney disease N Engl J Med, 2009.PMID 19880844
10. [10]Chertow GM, Block GA, Correa-Rotter R, et al. Effect of cinacalcet on cardiovascular disease in patients undergoing dialysis N Engl J Med, 2012.PMID 23121374
11. [11]Tangri N, Stevens LA, Griffith J, et al. A predictive model for progression of chronic kidney disease to kidney failure JAMA, 2011.PMID 21482743