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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References13ShowHide

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