Red Flags
- AKI on background CKD (creatinine rise ≥0.3 mg/dL within 48 h or ≥1.5× baseline within 7 days) — pause nephrotoxins, urgent nephrology if not resolving[1]
- 5-year kidney failure risk ≥10% on KFRE — prepare for kidney replacement therapy; access planning, transplant evaluation if eligible[1]
- Symptomatic uraemia or refractory hyperkalaemia >6.0 mmol/L — emergency dialysis evaluation[1]
- eGFR fall >25% within 4 weeks of starting RAS inhibitor or SGLT2 inhibitor — investigate for renal artery stenosis, volume depletion, or nephrotoxin co-administration; the expected SGLT2 dip is up to ~10%[1]
First-line treatment
Interventions
- Comprehensive cardio-renal protective bundle[1]All adults with CKD: RAS inhibitor + SGLT2 inhibitor (when eGFR ≥20 with ACR ≥30 mg/g) + statin per CV risk + smoking cessation + sodium <2 g/day; add finerenone in T2DM with persistent albuminuria; add GLP-1 RA in T2DM with elevated CV risk
- Blood-pressure target SBP <120 mm Hg by standardised office measurement[1]Adults with CKD without diabetic nephropathy. Standardised KDIGO measurement protocol critical (automated, seated rest 5 min, correct cuff, ≥2 readings averaged). Individualise in frail elderly and severe orthostatic intolerance
- Plant-based protein-moderated diet 0.8 g/kg/day[1]Non-dialysis CKD G3–G5; dietitian-led; emphasis on plant-based protein for lower phosphate and acid load; adjust upward (1.0–1.2 g/kg) on dialysis
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| ACE inhibitor or ARB[1] | RAS inhibitor | Ramipril 2.5–10 mg PO daily; lisinopril 10–40 mg PO daily; losartan 50–100 mg PO daily; titrate to maximum tolerated | — | All with diabetic CKD or UACR ≥30 mg/g; titrate to maximum tolerated; tolerate eGFR fall up to 30%; check K and creatinine 1–2 weeks after change |
| Dapagliflozin or empagliflozin[1] | SGLT2 inhibitor | Dapagliflozin 10 mg PO daily; empagliflozin 10 mg PO daily | — | Adults with CKD and ACR ≥30 mg/g regardless of diabetes status; start at eGFR ≥20; continue until KRT initiation; sick-day rules; risk of euglycaemic DKA, mycotic genitourinary infection |
| Finerenone[1] | Non-steroidal mineralocorticoid receptor antagonist | 10–20 mg PO once daily — start 10 mg if eGFR 25–60 or K ≤4.8; titrate after 4 weeks | — | Adults with T2DM and CKD with persistent ACR ≥30 mg/g despite optimal RAS inhibitor + SGLT2 inhibitor; avoid eGFR <25 or K >5.0 |
| Atorvastatin or rosuvastatin[1] | HMG-CoA reductase inhibitor | Atorvastatin 20–80 mg PO daily; rosuvastatin 5–20 mg PO daily (renal-adjusted) | — | Primary and secondary cardiovascular prevention in CKD G3a–G5 not on dialysis; benefit unproven in dialysis patients started afresh |
| GLP-1 receptor agonist[1] | Glucagon-like peptide-1 receptor agonist | Semaglutide 0.25 mg SC weekly start, titrate to 1 mg; liraglutide 0.6 mg SC daily start, titrate to 1.8 mg | — | T2DM + CKD with elevated cardiovascular risk; complementary to SGLT2 inhibitor; nausea and weight loss expected; not a primary kidney protector |
ACE inhibitor or ARB[1]
RAS inhibitor
- Adult
- Ramipril 2.5–10 mg PO daily; lisinopril 10–40 mg PO daily; losartan 50–100 mg PO daily; titrate to maximum tolerated
- Paediatric
- —
All with diabetic CKD or UACR ≥30 mg/g; titrate to maximum tolerated; tolerate eGFR fall up to 30%; check K and creatinine 1–2 weeks after change
Dapagliflozin or empagliflozin[1]
SGLT2 inhibitor
- Adult
- Dapagliflozin 10 mg PO daily; empagliflozin 10 mg PO daily
- Paediatric
- —
Adults with CKD and ACR ≥30 mg/g regardless of diabetes status; start at eGFR ≥20; continue until KRT initiation; sick-day rules; risk of euglycaemic DKA, mycotic genitourinary infection
Finerenone[1]
Non-steroidal mineralocorticoid receptor antagonist
- Adult
- 10–20 mg PO once daily — start 10 mg if eGFR 25–60 or K ≤4.8; titrate after 4 weeks
- Paediatric
- —
Adults with T2DM and CKD with persistent ACR ≥30 mg/g despite optimal RAS inhibitor + SGLT2 inhibitor; avoid eGFR <25 or K >5.0
Atorvastatin or rosuvastatin[1]
HMG-CoA reductase inhibitor
- Adult
- Atorvastatin 20–80 mg PO daily; rosuvastatin 5–20 mg PO daily (renal-adjusted)
- Paediatric
- —
Primary and secondary cardiovascular prevention in CKD G3a–G5 not on dialysis; benefit unproven in dialysis patients started afresh
GLP-1 receptor agonist[1]
Glucagon-like peptide-1 receptor agonist
- Adult
- Semaglutide 0.25 mg SC weekly start, titrate to 1 mg; liraglutide 0.6 mg SC daily start, titrate to 1.8 mg
- Paediatric
- —
T2DM + CKD with elevated cardiovascular risk; complementary to SGLT2 inhibitor; nausea and weight loss expected; not a primary kidney protector
Safety-net
- Sick-day rules — temporarily hold ACE inhibitor/ARB, SGLT2 inhibitor, finerenone, metformin, NSAIDs, and diuretics during dehydrating illness; restart when eating and drinking normally[1]
- Avoid NSAIDs (ibuprofen, diclofenac, naproxen) including over-the-counter and topical preparations — they accelerate CKD[1]
- Inform every prescriber and radiographer of your kidney function — many drugs and contrast agents need dose adjustment or substitution[1]
Referral criteria
- 5-year kidney failure risk ≥5% on KFRENephrology[1]
- Sustained eGFR fall ≥25% within 12 months, accelerated decline >5 mL/min/year, or new ACR ≥220 mg/mmolNephrology[1]
- Resistant hypertension, suspected genetic kidney disease, glomerulonephritis, or unexplained anaemiaNephrology[1]
- Pregnancy with CKDJoint nephrology and obstetric clinic[1]
Clinical summary
Diagnosis, classification by eGFR and albuminuria, prognosis, and progression-modifying therapy in adults with CKD; SGLT2 + RAS + finerenone framework.