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.