Definition

• Abnormality of kidney function or structure >3M, with implications for health

CKD stages

• Stage 1 (GFR >90) Kidney damage with normal or increased GFR. Complications: hypertension. Annual testing

• Stage 2 (GFR 60-89) Kidney damage with mild reduced GFR. Annual testing

• Stage 3a (GFR 45-59) 3b (GFR 30-44) moderate reduced GFR. Complications: hypertension, Ca/Ph changes, anaemia, LVF. Test every 6M

• Stage 4 (GFR 15-29) severe reduced GFR. Complications: above + hyperkalaemia. Testing every 3-6M

• Stage 5 (GFR <15) established renal failure. Complications: above + salt/water retention. Test every 6 weeks. 

Management

A low-cost renin angiotensin system antagonist, e.g. angiotensin-converting enzyme (ACE) inhibitor or angiotensin-II receptor antagonist (AIIRA), is not recommended for all patients with CKD. It should only be used for people with CKD and evidence of kidney damage (elevated urinary albumin:creatinine ratio (ACR)).

Atorvastatin 20 mg is recommended for primary prevention of cardiovascular disease in people with CKD.

Antiplatelet agents are not indicated for primary prevention of cardiovascular disease but may still be used in secondary prevention.

Routine supplementation with vitamin C, vitamin D, folic acid or carnitine is not recommended for CKD management. The National Institute for Health and Care Excellence does not recommend low protein diets for adults with CKD. 

Pain

A 53-year-old man has chronic kidney disease (CKD) with an eGFR of 16 ml/min. He has severe chronic pain and requires an opioid for pain control.

Opioids that are transformed to active or toxic metabolites and are dependent on the kidneys for excretion should be avoided, e.g. codeine, morphine, pethidine and tramadol.

Opioids that are least likely to cause harm to patients with severe renal impairment are fentanyl and buprenorphine.

Resources

• NICE. Chronic kidney disease: assessment and management. NG203. 2021 (updated 2021)

• CKD - not diabetic (CKS)

• Chronic kidney disease (Patient.info)

• Chronic kidney disease (NHS Choices)​

• Kidney information, conditions and treatments (Kidney Research UK)