Chronic Kidney Disease (CKD)

CKD affects approximately 1.7 million Australians and carries a substantially elevated cardiovascular risk — patients with CKD have up to a 20-fold greater risk of cardiovascular death before even reaching dialysis, with a 2–3-fold greater risk of cardiac death than those without CKD.

Definition

An estimated or measured GFR <60 mL/min present for ≥3 months, with or without evidence of kidney damage — or evidence of kidney damage (with or without decreased GFR) present for ≥3 months, irrespective of underlying cause:

• Albuminuria
• Haematuria after exclusion of urological causes
• Structural abnormalities (e.g. on kidney imaging)
• Pathological abnormalities (e.g. renal biopsy)

Who is at risk?

Age ≥60, diabetes, smoking, hypertension, established cardiovascular disease, Aboriginal or Torres Strait Islander background, family history of kidney failure, prior AKI (see acute-kidney-injury.md), obesity (BMI ≥30).

Screening

• Every 1–2 years for anyone with risk factors; every 2 years for Aboriginal/Torres Strait Islander patients over 30 with no other risk factors
• Those without risk factors should have the risk factors themselves re-assessed yearly
• Test: eGFR + urine ACR (first morning void preferred), plus BP
• Offer behavioural intervention advice (smoking cessation, weight loss, etc.) to anyone with risk factors

Clinical presentation

CKD is generally asymptomatic — up to 90% of kidney function may be lost before symptoms appear, and many patients notice nothing until Stage 5. Early, non-specific signs can include hypertension, pruritus, nocturia, restless legs, haematuria, dyspnoea, lethargy, nausea/vomiting, malaise, anorexia.

Staging

Staging combines eGFR category (G1–G5) with albuminuria category (A1–A3); thresholds vary slightly by age and sex. Combine both plus the underlying diagnosis to fully specify CKD (e.g. “Stage 2 CKD with microalbuminuria due to diabetic kidney disease”).

eGFR category	eGFR (mL/min/1.73m²)
G1	≥90
G2	60–89
G3a	45–59
G3b	30–44
G4	15–29
G5	<15

Albuminuria category	Urine ACR
A1 (normal–mild)	Male <2.5, Female <3.5 mg/mmol
A2 (microalbuminuria)	Male 2.5–25, Female 3.5–35 mg/mmol
A3 (macroalbuminuria)	Male >25, Female >35 mg/mmol

A ≥20% reduction in eGFR, or two reduced eGFR results within 3 months (repeat within 7 days to confirm), should prompt consideration of possible acute kidney injury and nephrology discussion. Repeat abnormal urine ACR twice within 3 months (preferably first morning void) before accepting the result as a minimum of 2 out of 3 elevated readings.

Initial work-up for newly-detected CKD

• Renal ultrasound
• Repeat UEC/eGFR/albumin within 1 week (if eGFR continues to fall, manage as AKI — see acute-kidney-injury.md)
• FBC, CRP, ESR
• Urine ACR (preferably first morning void)
• Fasting lipids and glucose
• Urine microscopy for dysmorphic red cells, red cell casts or crystals

If signs of systemic disease are present (rash, arthritis, connective tissue disease features, pulmonary symptoms, or deteriorating kidney function), consider: anti-GBM antibody, ANCA, ANA, extractable nuclear antigens, complement studies. If HBV/HCV/HIV risk factors: serology. If age >40 with possible myeloma: serum and urine protein electrophoresis.

Clinical action plans by risk tier

Tier	Criteria	Review frequency	Key actions
Yellow	eGFR ≥60 with microalbuminuria, or eGFR 45–59 with normoalbuminuria	Every 12 months	Investigate underlying cause; assess absolute CV risk; BP/lifestyle/lipid management; avoid nephrotoxic drugs/volume depletion
Orange	eGFR 30–59 with microalbuminuria, or eGFR 30–44 with normoalbuminuria	Every 3–6 months	As above, plus FBC, calcium/phosphate, PTH (6–12 monthly if eGFR ≤45); early complication detection; dose-adjust medications; refer to nephrology if indicated
Red	Macroalbuminuria irrespective of eGFR, or eGFR <30 irrespective of albuminuria	Every 1–3 months	As above, plus oedema assessment; prepare for kidney replacement therapy or non-dialysis supportive care if progressing; discuss advance care plans if appropriate — see dialysis.md

Disease-modifying therapy

SGLT2 inhibitors are now foundational CKD-progression therapy, per the 2024 KDIGO CKD guideline’s strong (1A) recommendation — independent of diabetes status, initiation is recommended down to eGFR ≥20 mL/min/1.73m², with continuation even as eGFR declines further. Dapagliflozin and empagliflozin both carry specific CKD-progression indications (not just a diabetes indication) based on the DAPA-CKD and EMPA-KIDNEY trials. Finerenone (a non-steroidal mineralocorticoid receptor antagonist) is an add-on option for diabetic CKD with albuminuria (FIDELIO-DKD/FIGARO-DKD trials). SGLT2i should now be considered alongside ACEi/ARB as first-line therapy, not merely a diabetes drug needing dose caution.

GLP-1 receptor agonists: in adults with type 2 diabetes and CKD who have not reached individualised glycaemic targets despite metformin and an SGLT2 inhibitor, or who cannot use those drugs, a long-acting GLP-1 receptor agonist is now recommended, prioritising agents with proven cardiovascular benefit that need no CKD dose adjustment — liraglutide, semaglutide (injectable) and dulaglutide. Pooled trial data show reduced major cardiovascular events regardless of baseline kidney function, plus a modest reduction in heart failure hospitalisation and all-cause mortality.

RAS inhibitor use specifically in advanced CKD (G4–G5) — a genuine grey area

RAS inhibition (ACEi/ARB) is well-established as the cornerstone of slowing early CKD progression and reducing cardiovascular risk — but its role in advanced CKD (G4–G5) is less clear, since this population was underrepresented in the pivotal trials. KDIGO 2021 gives only a weak recommendation for RASI in CKD G4 and no consensus recommendation for G5, due to a lack of randomised data on the risk-benefit of continuing vs stopping.

• Arguments for continuing: several large observational studies link RASI discontinuation with increased mortality and progression to end-stage kidney disease; one prospective cohort of >28,000 advanced-CKD patients found RASI therapy associated with up to 5.5% lower annual risk of long-term dialysis; benazepril use in advanced CKD showed a 40% lower ESKD incidence and slower eGFR decline in another trial
• Arguments for stopping: conversely, some studies (e.g. Fu et al 2021, n=10,254, eGFR <30) found RASI cessation associated with a lower absolute risk of needing renal replacement therapy, with eGFR improving after stopping in some patients
• Practical takeaway: the STOP-ACEi trial has now reported (411 participants, mean eGFR 13 mL/min/1.73m²) — a policy of discontinuing RASi in CKD G4–G5 gave no kidney or cardiovascular benefit over continuing, and KDIGO 2024 now explicitly recommends continuing ACEi/ARB even as eGFR falls below 30 mL/min/1.73m². Starting new RASi in this population remains less certain (the formal recommendations are scoped to G1–G4), so the individualised weighing — multimorbidity, polypharmacy, functional status, BP, goals of care, and a clear plan for monitoring/managing hyperkalaemia — still applies mainly to initiation, not to whether to keep going once started.

Treatment goals

Diet and nutrition: salt <5g/day (sodium <2g/day); varied, low-fat diet avoiding saturated/trans fats; water to satisfy thirst (avoid sweetened/carbonated drinks); dietary protein no lower than 0.7g/kg/day; maintain serum albumin ≥35g/L.

Weight: BMI <25; waist circumference <94cm (men)/<80cm (women).

Physical activity: 150–300 min/week moderate intensity, or 75–150 min/week vigorous.

Smoking: cessation is a high priority.

Alcohol: no more than 2 standard drinks/day (14/week, max 4 on any occasion).

Glycaemic control (if diabetic): BGL 6–8 mmol/L fasting or 8–10 mmol/L post-prandial; HbA1c ≤7%.

Albuminuria: aim for 50% reduction in urine ACR.

Blood pressure: target systolic BP <120mmHg (when tolerated), measured using standardised office technique — a lower, more intensive target than the traditional <130/80 mmHg, adopted by KDIGO in 2024. Standardised measurement typically reads several mmHg lower than routine clinic BP. Use less intensive BP-lowering in frailty, high falls/fracture risk, very limited life expectancy, or symptomatic postural hypotension.

Lipids: age ≥50 with eGFR <60 — statin, or statin/ezetimibe combination (KDIGO 2024, strong recommendation); age ≥50 with eGFR ≥60 — statin alone; age 18–49 — statin if known coronary disease, diabetes, prior ischaemic stroke, or an estimated 10-year coronary event risk >10%. Choose a regimen that maximises the absolute LDL reduction rather than chasing a specific target number; consider a PCSK9 inhibitor as an add-on where otherwise indicated, and a plant-based “Mediterranean-style” diet alongside drug therapy.

Antiplatelet therapy: low-dose aspirin is recommended for secondary prevention in people with CKD and established ischaemic cardiovascular disease; consider a P2Y12 inhibitor if aspirin-intolerant.

Metabolic acidosis: consider pharmacological treatment (sodium bicarbonate) with or without dietary adjustment if serum bicarbonate falls below 18 mmol/L, to prevent the muscle wasting, impaired cardiac function and other complications associated with chronic acidosis; a lower-protein, more plant-based (“alkaline”) diet is a reasonable adjunct. Monitor to avoid overshooting the upper limit of normal, or worsening BP/fluid status.

Hyperuricaemia: offer urate-lowering therapy for symptomatic hyperuricaemia (gout) in people with CKD — the evidence shows no increased risk of hepatotoxicity or cutaneous hypersensitivity reactions from urate-lowering drugs in this population, so CKD itself should not be a reason to withhold treatment.

Anaemia: if Hb 100–115 g/L, trial iron to maintain ferritin >100 µg/L; if unsuccessful, start an erythropoiesis-stimulating agent, targeting ferritin 200–500 µg/L and TSAT 20–30%.

Potassium: keep below 6.0 mmol/L. See Electrolyte Disorders for managing hyperkalaemia by severity.

Immunisations: influenza and pneumococcal recommended for all with end-stage kidney disease and/or diabetes.

Hypertension management algorithm

Target systolic BP <120mmHg (standardised office measurement, when tolerated) for all CKD stages.

1. If BP is consistently at target: continue monitoring + lifestyle measures
2. If not at target: start ACE inhibitor or ARB; monitor eGFR and potassium
3. Still not at target: reinforce adherence, increase ACEi/ARB to maximum recommended dose, consider adding a calcium channel blocker, diuretic, or beta-blocker
4. Refer to nephrology if BP remains above target despite ≥3 antihypertensive agents

Drugs needing dose reduction or caution in CKD

Acarbose, apixaban, dabigatran, exenatide, gabapentin, glimepiride, lithium, opioid analgesics, saxagliptin, spironolactone, vildagliptin, allopurinol, benzodiazepines, digoxin, famciclovir, glibenclamide, glipizide, metformin (caution if GFR 30–60, not recommended below that, interrupt temporarily during illness/GFR change), pregabalin, sitagliptin, trimethoprim (raises creatinine without affecting true GFR — don’t mistake for worsening renal function), antivirals, colchicine, denosumab, fenofibrate, gliclazide, insulin, NSAIDs, rivaroxaban, sotalol, valaciclovir.

Drugs that can adversely affect kidney function directly: aminoglycosides, calcineurin inhibitors, gadolinium, lithium, NSAIDs/COX-2 inhibitors (beware the “triple whammy” of NSAID+ACEi/ARB+diuretic together), radiographic contrast agents.

For dosing across the full range of renal impairment beyond the specific updates above, The Renal Drug Handbook (3rd ed) is held privately as evidence for this category — cite by name only for any specific dose, and cross-check against current eTG/AMH before prescribing, since renal drug-dosing guidance changes between editions.

Indications for nephrology referral

Appropriate referral is associated with reduced progression to ESKD, decreased morbidity/ mortality, shorter/less frequent hospitalisation, and better-timed dialysis access/ transplantation planning.

Refer if:

• eGFR <30 mL/min/1.73m² (Stage 4 or 5 CKD of any cause)
• Persistent significant albuminuria (urine ACR ≥30 mg/mmol)
• A sustained eGFR decrease of ≥25% within 12 months, or ≥15 mL/min/1.73m²/year
• CKD with hypertension not controlled on ≥3 antihypertensive agents

Referral not necessary (absent other indications): stable eGFR ≥30 mL/min, urine ACR <30 mg/mmol without haematuria, controlled BP. The decision should always be individualised — indications may be less stringent in younger patients. A letter/email/phone discussion with a specialist can resolve management questions without requiring a formal specialist visit.

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Sources: https://kidney.org.au/uploads/resources/chronic-kidney-disease-management-in-primary-care-4th-edition-handbook_2020-07-16-064708.pdf, https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/red-book/prevention-of-vascular-and-metabolic-disease/kidney-disease, https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/national-guide/chapter-13-chronic-kidney-disease-prevention-and-m