Dr Kola Tytler MBBS CertHE MBA MRCGPClinical Lead • iatroX
For patients with a confirmed diagnosis of chronic kidney disease (CKD), primary care should arrange regular follow-up, with the frequency determined by clinical judgment. Management involves assessing and managing risk factors and comorbidities, including the underlying causes of CKD and any potentially nephrotoxic drugs NICE CKS,NICE CKS.
Key Management Areas:
For specialist consideration:
Key Management Areas:
- Monitoring: Regularly monitor for disease progression, adjusting frequency based on CKD stage and risk factors NICE CKS,NICE CKS.
- Hypertension Management: Assess for hypertension. For those with an ACR over 30 mg/mmol, offer an ACE inhibitor or ARB as first-line treatment, titrated to the highest tolerated dose. Do not combine renin-angiotensin system antagonists. Blood pressure targets vary based on ACR: < 70 mg/mmol aim for <140/90 mmHg (120-139/80-89 mmHg), and >= 70 mg/mmol aim for <130/80 mmHg (120-129/70-79 mmHg). For individuals aged 80+ with type 1 diabetes, aim for <150/90 mmHg NICE CKS,NICE CKS.
- Lifestyle Modifications: Encourage exercise, healthy weight, and smoking cessation NICE NG203.
- Dietary Advice: Offer advice on potassium, phosphate, calorie, and salt intake, tailored to CKD severity. Ensure dietary advice is provided with education and supervision to prevent malnutrition NICE NG203. Do not offer low-protein diets (less than 0.6 to 0.8 g/kg/day) NICE NG203.
- Information and Education: Provide high-quality, tailored information and education programmes to patients and their families/carers to facilitate informed choices about treatment and self-management NICE NG203.
- Psychological Support: Address psychological aspects of coping with CKD and offer access to support services NICE NG203.
- Risk Assessment: Inform patients about their 5-year risk of needing renal replacement therapy using the 4-variable Kidney Failure Risk Equation NICE NG203.
For specialist consideration:
- Referral to a nephrology specialist is indicated if hypertension remains uncontrolled despite at least four antihypertensive drugs at therapeutic doses NICE CKS,NICE CKS.
- Referral criteria for specialist assessment include a 5-year risk of needing renal replacement therapy greater than 5%, an ACR of 70 mg/mmol or more (unless appropriately treated for diabetes), an ACR over 30 mg/mmol with haematuria, a sustained eGFR decrease of 25% or more within 12 months, a sustained eGFR decrease of 15 ml/min/1.73 m² or more per year, known or suspected rare/genetic causes of CKD, or suspected renal artery stenosis NICE NG203.
- Refer to urology for renal outflow obstruction NICE CKS,NICE CKS.
- Consider discussing management with a specialist if there are concerns but referral is not immediately necessary NICE CKS,NICE CKS.
- Specific medications may require dose adjustments or avoidance in renal impairment, such as ACE inhibitors (start low, adjust as tolerated) Products, potassium citrate/bicarbonate (avoid if eGFR < 45 mL/min/1.73m², caution if 45-59 with elevated potassium) Products, potassium chloride (avoid in severe impairment, monitor closely) Products, and atorvastatin (initial dose 20mg, specialist advice for eGFR < 30) Products. Finerenone should be avoided if eGFR < 25 mL/min/1.73m² Products. Tobramycin requires annual renal function monitoring Products.