Chronic kidney disease — assessment and management

Red Flags

Acute kidney injury on background CKD (creatinine rise ≥26.5 µmol/L within 48 h, ≥1.5× baseline within 7 days, or oliguria) — pause nephrotoxins, urgent nephrology if not resolving^[1]
eGFR <15 mL/min/1.73 m² (CKD G5) — kidney replacement therapy preparation; transplant assessment if eligible^[1]
Symptomatic uraemia (vomiting, pruritus, encephalopathy, pericardial rub) — emergency dialysis evaluation^[1]
Hyperkalaemia >6.0 mmol/L — ECG and emergency potassium-lowering management; review RAS inhibitor and dietary potassium^[1]

First-line treatment

Interventions

Cardiovascular risk reduction^[1]
Statin (atorvastatin 20 mg first-line per NICE) for all adults with CKD; manage smoking, BP, diabetes; consider antiplatelet for established cardiovascular disease (not for primary prevention)
Blood-pressure target^[1]
<140/90 mm Hg generally; <130/80 if albuminuria (ACR ≥70 mg/mmol) or diabetes; standardised office BP measurement; combine with home or ambulatory monitoring
Sodium <2 g/day, weight management, avoid nephrotoxins (NSAIDs, certain herbal preparations, IV contrast where avoidable)^[1]
Cornerstone lifestyle and prescribing care; medication review at each visit
Anaemia, bone, and metabolic management^[1]
Hb monitoring with iron stores when eGFR <60 and Hb falls; oral iron then IV; ESA when Hb <100 g/L on adequate iron; phosphate, calcium, PTH, 25-OH vitamin D per CKD-MBD pathway

First-line drug therapy

Drug	Class	Adult	Paediatric	Notes
ACE inhibitor or ARB^[1]	Renin-angiotensin-aldosterone system inhibitor	Ramipril 2.5–10 mg PO daily; lisinopril 10–40 mg PO daily; losartan 50–100 mg PO daily; titrate to maximum tolerated	—	Offer to all adults with diabetic CKD or UACR ≥30 mg/mmol; titrate to maximum tolerated; tolerate eGFR fall ≤25% from baseline; 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	—	Offer to adults with CKD and ACR >30 mg/mmol regardless of diabetes status (NICE 2023 update); start at eGFR ≥20; continue until kidney replacement therapy; expect transient eGFR dip; sick-day rules
Finerenone^[1]	Non-steroidal mineralocorticoid receptor antagonist	10–20 mg PO once daily; titrate by potassium and eGFR	—	Adults with type 2 diabetes and CKD with persistent albuminuria despite ACEi/ARB and SGLT2 inhibitor; avoid eGFR <25 or K >5.0 at start
Atorvastatin^[1]	HMG-CoA reductase inhibitor	20 mg PO daily; up-titrate per response and risk	—	Primary and secondary prevention in CKD; monitor LFTs and CK; safe in CKD G3a–G4; cautious in G5 dialysis (no clear mortality benefit)

ACE inhibitor or ARB^[1]

Renin-angiotensin-aldosterone system 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: —

Offer to all adults with diabetic CKD or UACR ≥30 mg/mmol; titrate to maximum tolerated; tolerate eGFR fall ≤25% from baseline; 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: —

Offer to adults with CKD and ACR >30 mg/mmol regardless of diabetes status (NICE 2023 update); start at eGFR ≥20; continue until kidney replacement therapy; expect transient eGFR dip; sick-day rules

Finerenone^[1]

Non-steroidal mineralocorticoid receptor antagonist

Adult: 10–20 mg PO once daily; titrate by potassium and eGFR
Paediatric: —

Adults with type 2 diabetes and CKD with persistent albuminuria despite ACEi/ARB and SGLT2 inhibitor; avoid eGFR <25 or K >5.0 at start

Atorvastatin^[1]

HMG-CoA reductase inhibitor

Adult: 20 mg PO daily; up-titrate per response and risk
Paediatric: —

Primary and secondary prevention in CKD; monitor LFTs and CK; safe in CKD G3a–G4; cautious in G5 dialysis (no clear mortality benefit)

Safety-net

Sick-day rules — temporarily hold ACE inhibitor/ARB, diuretic, SGLT2 inhibitor, NSAID, and metformin during dehydrating illness; restart when eating and drinking normally^[1]
Avoid NSAIDs (ibuprofen, diclofenac, naproxen) — they accelerate CKD; check labels including topical and over-the-counter preparations^[1]
If you need a CT scan with contrast — tell the radiologist about your kidney function so they can use a low-osmolar agent and minimum volume with hydration before and after^[1]

Referral criteria

5-year kidney failure risk ≥5% on KFRENephrology^[1]
Sustained eGFR fall ≥25% within 12 months, or fall ≥15 mL/min/year, or new ACR ≥70 mg/mmolNephrology^[1]
Resistant hypertension, suspected genetic kidney disease, suspected glomerulonephritis, or unexplained anaemiaNephrology^[1]
Pregnancy with CKDJoint nephrology and obstetric clinic^[1]

Clinical summary

Diagnosis, classification, prognosis, and progression-modifying therapy in adults with chronic kidney disease, including SGLT2 inhibitors and finerenone.

References

1.NICE NG203 — Chronic Kidney Disease: Assessment and Management (2021, updated 2023 with SGLT2 inhibitor recommendations) (2023)