KISS: Chronic Kidney Disease | NB Medical

KISS: Chronic Kidney Disease

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Based on NICE NG203, 2021 & NICE TA775, 2022 & TA942 2023


  • CKD is classified according to estimated GFR and proteinuria using albumin-creatinine ratio (ACR):
    • G is used to denote the GFR category, G1-G5
    • A for the ACR category, A1-A3
  • Increased ACR and decreased GFR are associated with adverse outcomes.
  • Increased ACR and decreased GFR multiply these risks e.g. G2A1 = low risk of adverse outcomes, but G3bA2 = high risk and G3bA3 = very high risk (see heat map for risk according to GFR and A category).
GFR Category GFR Terms
G1 >90 Normal or high
G2 60-89 Mildly decreased relative to young adult level (NB: there is NO CKD for G1&2 in the absence of markers of kidney damage e.g. proteinuria)
G3a 45-59 Mild to moderate decrease
G3b 30-44 Moderate to severe decrease
G4 15-29 Severely decrease
G5 <15 Kidney Failure
CKD: urine Albumin Creatinine Ratio (ACR) categories
ACR category ACR (mg/mmol) Terms
A1 <3 Normal
A2 3-30 Moderate increase; clinically important with increased risk of adverse outcomes
A3 >30 Severely increased


  • eGFR testing:
    • If the first discovery of low eGFR/raised creatinine, clinically assess carefully and if well repeat the test within 14 days to exclude acute kidney injury. If eGFR is stable, repeat again at 3 months to see if it is sustained. 
    • If low eGFR is sustained >90 days, CKD is diagnosed.
    • Interpret eGFR with caution in those with extremes of muscle mass e.g. reduced muscle mass will lead to over-estimation of eGFR this has implications when interpreting levels of frailty.
  • Proteinuria Testing:
    • Do not use reagent strips to identify proteinuria, test for CKD with eGFR and ACR.
    • If the initial ACR is between 3 and 70, this should be confirmed with an early morning sample:
      • Confirmed ACR > 3 is considered clinically important.
    • If the initial level is over 70, a repeat is not needed.
  • Indications for renal ultrasound:
    • Accelerated progression of CKD.
    • Persistent invisible haematuria.
    • Symptoms of urinary tract obstruction.
    • Family history of polycystic kidney disease.
    • GFR category G4 or G5.

Chronic Kideny Disease: Management:

NICE NG203, 2021  Cochrane 2023  BJGP2018;68:356  NICE TA775, 2022  TA942 2023  BMJ 2023;383:e074216


  • Optimise risk factors e.g. lifestyle, hypertension, diabetes etc & direct patients to Information Sources.

Monitor for progression:

  • Regular monitoring of eGFR:
    • G1-3a at least annually, G3b-G4 at least 6 monthly, G5 3 monthly.
  • Check for accelerated progression:
    • = a change in G category & a sustained decrease in eGFR of >25%, or a decrease in eGFR of 15 per year.
  • Assess the 5-year risk of needing renal replacement Kidney Failure Risk Equation.

Reducing cardiovascular risk, anaemia and bones:

  • Lifestyle advice; avoid NSAIDs.
  • Lower BP: Target BP < 140/90; lower target <130/80 if ACR> 70.
    • Follow usual hypertension guidelines if ACR < 30 (i.e. groups A1 and A2).
    • Offer ACEi or ARB if ACR > 30 (A3).
      • ACEi and ARBs may be associated with a temporary fall in eGFR after starting ACEi or ARBs of up to 25% or rise in Cr of 30% - if so repeat after 1-2 weeks but don't change dose and accept a drop in eGFR <25% or a rise in Cr <30%.
      • Seek specialist advice if sustained and significant change. 
      • Do not start if serum K >5, and stop if serum K >6.
  • Proteinuria:
    • If CKD and diabetes (NG28 Nov 2021) offer ACEi or ARB if ACR > 3.
    • If CKD without diabetes, refer for nephrology assessment if ACR > 70.
  • SGLT inhibitors dapagliflozin and empagliflozin are now an option as add on to max tolerated ACEi/ARB:
    • Dapagliflozin if eGFR of 25-75 ml/min/1.73 m2 AND type 2 diabetes OR have a urine ACR of ≥ 22.6 mg/mmol.
    • Empagliflozin if eGFR of 20-45 ml/min/1.73 m2 OR
      • eGFR 45-90 ml/min/1.73 m2 AND either a urine ACR of ≥22.6 mg/mmol or type 2 diabetes.
  • Statins: offer atorvastatin 20mg to  patients with CKD not requiring dialysis for 10 and 20 prevention of CVD NICE2023
    • if the target is not met, and eGFR is > 30 then increase the dose; if eGFR is < 30 get specialist renal advice.
  • Antiplatelets - offer only for secondary prevention of CVD.
  • Anaemia: Consider investigating and managing anaemia in adults with CKD if Hb ≤ 110 g/L:
    • If eGFR is > 60 ml/min investigate other causes of anaemia as it is unlikely to be due to CKD.
    • If eGFR is 30 - 60 ml/min investigate other causes of anaemia, but use clinical judgement to decide how extensive those investigations should be as the anaemia may be caused by CKD.
    • If eGFR is < 30 ml/min think about other causes, but note anaemia is often caused by CKD.
  • Bones
    • Serum calcium, phosphate and PTH levels need to be measured in patients with category G4 or G5 (i.e. eGFR<30) and obtain specialist advice. Offer cholecalciferol to treat Vit D deficiency if found.

Referral criteria

  • 5-year risk of needing renal replacement therapy > 5% using the Kidney Failure Risk Equation.
  • Stage A3 (ACR>30) plus haematuria OR ACR >70, unless secondary to diabetes and on treatment.
  • Accelerated progression (see monitoring above).
  • Hypertension is poorly controlled despite at least 4 drugs at therapeutic doses.
  • Suspected renal artery stenosis, or suspected rare or genetic cause.
Published on 3rd July 2024

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