Chronic kidney disease (CKD) - Clinical template
History:
Reviewed Pre-consultation Patient Questionnaire? Suspicion of CKD? - Risk factors for CKD? - Incidental finding of:
-- Raised serum creatinine?
-- eGFR < 60 ml/min/1.73 m2?
-- Urine ACR > 3 mg/mmol?
-- Persistent haematuria (two or of three urine dipstick tests show 1+ or more of blood) after exclusion of a urinary tract infection (UTI)?
-- Urine sediment abnormalities:
--- Red blood cells (may indicate glomerular disease)?
--- White blood cells (may indicate pyelonephritis or interstitial nephritis)?
--- Granular casts and renal tubular epithelial cells (seen in many parenchymal diseases)?
- Possible clinical features of CKD?
Examination:
Nutritional status (eg cachexia or signs of malnutrition)? Pallor?
Dehydration or hypovolaemia?
Cognitive impairment? - Language?
- Orientation?
- Attention?
Height?
Weight?
BMI?
BP?
Dyspnoea?
Flank mass?
Palpable distended bladder? Peripheral oedema? Peripheral neuropathy? - Paraesthesia?
- Restless legs syndrome?
- Sleep disturbance?
Myopathy? Rashes (eg ecchymosis, purpura)? Signs of other systemic causes (eg LE)? Uraemic odour (ammonia-like smell or the breath, may be present in advanced disease)?
Investigations:
Checked if required lab results were available and requested them if outstanding?
Serum creation and estimated glomerular filtration rate (eGFR)
(Not to eat meat for at least 12 hours before the test)
< 60 ml/min/1.73 m2?
- If yes, repeat the test within 2 weeks (unless the eGFR is stable)
< 60 ml/min/1.73 m2 on repeat + no evidence of sudden deterioration in renal function suggesting acute kidney injury?
- If yes, repeat eGFR in 3 months
(Note: Interpret the eGFR result with caution if the person has extremes of muscle mass, is pregnant, has oedema, is malnourished or uses protein supplements, or black, Asian, or other minority ethnic groups. Allow for biological and analytical variability of serum creatinine (+/- 5%))
Early morning urine sample for urinary albumin:creatinine ratio (uACR)?
< 3 mg/mmol (no proteinuria)?
- If yes, no action needed
3-70 mg/mmol?
- If yes, repeat within 3 months
≥ 70 mg/mmol?
- If yes, repeat test not needed as indicative of significant proteinuria (see management in primary care)
(Note: Transient increases in urine ACR may be seen with menstruation, urinary tract infection (UTI), strenuous exercise, and upright posture ('orthostatic proteinuria'). Protein:creatinin ratio (PCR) can be used as an alternative to ACR.)
Urine dipstick test to check for haematuria:
1+ or more of blood?
- If yes, mid-stream urine sample (MSU) to exclude a UTI?
Persistent invisible haematuria (two out of three urine dipstick tests show 1+ or more of blood after exclusion of a UTI), with or without proteinuria, possibility of urinary tract malignancy in appropriate age group considered ( see Urological cancers - recognition and referral)?
Other:
HbA1c?
Lipid profile?
Renal tract ultrasound if indicated (eg suspected urinary tract stones or obstruction or a family history of polycystic kidney disease and is aged over 20 years)?
CKD category stages 3-5 (or if a person develops symptoms suggestive of anaemia)?
Full blood cell count (FBC)? If renal anaemia suspected, referral to a nephrology specialist?
CKD Category stages 4 or 5?
Serum calcium?
Phosphate?
Vitamin D?
Parathyroid hormone?
Annually if not been diagnosed with CKD, but ongoing risk factors for CKD? - Serum creatinine? - eGFR? - uACR? - Urine dipstick?
Diagnosis: Either of the following present for a minimum of 3 months: GFR < 60 mL/min/1.73 m2? Markers of kidney damage? - uACR > 3 mg/mmol? - Urine sediment abnormalities?
- Persistent haematuria? - Eletrolyte and other abnormalities due to tubular disorders - Abnormalities detected by histology? - Structural abnormalities detected by imaging? - History of kidney transplant? Classification of CKD?
(Note: A significant increase in serum creatinine, for example by more than 20%, may indicate significant renal impairment, in the presence of normal eGFR readings (eGFR greater than 90 mL min/1.73 m2).)
Management:
Identification and management of underlying causes and risk factors?
Agreed on frequency of monitoring (serum creatinine, eGFR, urinary ACR)?
(Note: Frequency of eGFR monitoring (number of times per year) for people with or at risk of CKD).
'Accelerated progression' (sustained decrease in eGFR of ≥ 25% from baseline and a change in CKD category within 12 months; or a sustained decrease in eGFR of ≥ 15 mL/min/1.73 m2 within 12 months)?
(Note: To assess the rate of progression, repeat eGFR 3 times over at least 3 months.)
Present?
- Assessment for any reversible causes (such as potentially nephrotoxic drugs or volume depletion)?
- Renal tract ultrasound scan?
- Referral to a specialist kidney service?
Risk of acute kidney injury (AKI)?
- Consideration of stopping nephrotoxic drugs?
- Monitoring for a least 2-3 years (even if serum creatinine had returned to baseline) after an episode of acute kidney injury (AKI)?
Any potentially nephrotoxic drugs that may cause AKI in severe intercurrent illness reduced or stopped? If discontinued during a period of acute illness clearly explained when it should be restarted?
Lifestyle risk factors for disease progression assessed and managed? Any associated anxiety or depression? Risk of cardiovascular disease (CVD)? (Note: Do not use a risk assessment tool to assess CVD risk in people with CKD.)
Hypertension? ACR < 30 mg/mmol?
< 140/90 mmHg (< 80 years)? < 140/90 mmHg ( ≥ 80 years)?
ACR > 30 mg/mmol?
ARB (eg Lorsartan) or ACE (titrated to the highest licensed dose the person can tolerate)?
(Notes: Check renal function + electrolytes before starting tx and 1-2 weeks after starting.
Initial reduction in eGFR and increase in potassium are common after initiation of RAS drugs, but this then stabilises and longer-term benefits are seen. As long as the decrease in eGFR is < 25% and the creatinine increase < 30% to continue to titrate to a maximally tolerated dose. If the drop in renal function exceeds this, review of causes for AKI (eg intercurrent illness, dehydration etc), BP, concurrent medications, and consider renal artery stenosis). If no reversible causes, consider stopping or reducing the dose of the RAS inhibitor.
K < 5.5 mmol/L can be tolerated. If well patient and no signs of AKI: If mild hyperkaleamia (K 5.5-5.9 mmol/L), half the dose. If moderate hyperkalaemia (K 6.0-6.4 mmol/L), stop the RAS inhibitor. In both cases repeat the renal function/L within 1 week whilst also looking for contributory causes (medication review, potassium rich foods including 'lo-salt' products) and considering if the initial result may have been an artefact (eg hemolysis, or a delay in sample processing).
BP target: ACR < 70 mg/mmol? < 140/90 mmHg (target 120-139/<90 mmHg) ACR ≥ 70 mg/mmol?
< 130/80 mmHg (target 120 to 129/<80 mmHg)?
≥ 80 years or T1DM (regardless of the ACR)?
BP < 150/90 mmHg (target 140 to 149/<90 mmHg)? Referral to nephrology specialist, if hypertension uncontrolled despite the use of at least four antihypertensive drugs?
Persistent proteinuria?
ACR > 70 mg/mmol? Referral for nephrology assessment? ARB (eg Lorsartan) or ACE? ACR 30-70 mg/mmol?
Monitoring?
Considered specialist advice from nephrologist? Persistent proteinuria + DM?
ACR > 3 mg/mmol?
Offered ARB (eg Lorsartan) or ACE (titrated to the highest licensed dose that is tolerated)?
Antiplatelet:
Antiplatelet offered?
Statin:
Atorvastatin 20 mg offered?
Increased if a greater than 40% reduction in non-HDL cholesterol is not achieved and eGFR is ≥ 30 ml/min/1.73 m2?
Agreed the use of higher doses with a renal specialist if eGFR < 30 ml/min/1.73 m2 (renal impairment risk factor for myopathy and rhabdomyolysis adverse effects of statins)?
Sodium-glucose cotransporter-2 inhibitor (SGLT2i): eGFR 20 to < 45? eGFR > 45 + uACR > 22.5 mg/mmol or T2DM? eGFR > 45 + uACR > 25 mg/mmol or T2DM or CHD or HF (BJGP)?
Dapagliflozin?
Empagliflozin?
Nonsteroidal minerlocorticoid receptor antagonist (NS-MRA): Considered finerenone (Kerendia) as an add on option for stage 3 or 4 CKD in patients with diabetes )K must be < 5, monitoring needed (see BNF)?
Vaccinations:
Offered influenza immunization?
Offered pneumococcal immunization?
5-year risk:
Informed about 5-year risk of needing renal replacement therapy (measured using the 4-variable Kidney Failure Risk Equation)?
Chronic Kidney Disease (CKD) - General Patient Information explained and provided to patient?
Advised:
About 5-year risk of needing renal replacement therapy (measured using the 4-variable Kidney Failure Risk Equation)?
Stop smoking if appropriate
Drink alcohol in moderation
Maintain a healthy body weight
Eat a healthy diet
(Note: A low-protein diet (dietary protein intake of less than 0.6-0.8 g/kg) not routineley recommended).
Take regular exercise
Avoid the use of over-the-counter non steroidal anti-inflammatory drugs (NSAIDS) where possible
Stop taking herbal remedies and other dietary supplements
Increased risk of acute kidney injury (AKI) if the is severe intercurrent illness
Provided sources of information, advice and support:
- Kidney Care UK (www.kidneycareuk.org) (national kidney charity with telephone support helpline (tel. 01420 541424) and several leaflets on CKD and associated conditions
- NHS patient information leaflet 'Chronic kidney disease’
- Patient UK information leaflet 'Chronic kidney disease'
Referral:
2-week referral:
Isolated persistent haematuria and suspicion of urological cancer?
Referral to nephrologist:
A 5-year risk of needing renal replacement therapy of greater than 5% (measured using the 4-variable Kidney Failure Risk Equation)?
Accelerated progression of CKD?
Urinary ACR ≥ 70 mg/mmol, unless proteinuria known to be associated with diabetes mellitus and is managed appropriately?
Urinary ACR ≥ 30 mg/mmol with persistent haematuria, after exclusion of a urinary tract infection (UTI)?
Hypertension that remains uncontrolled despite the use of at least four antihypertensive drugs at therapeutic doses?
A suspected or confirmed rare or genetic cause of CKD, such as polycystic kidney disease?
Suspected renal artery stenosis (should be suspected if there is a greater than 25% reduction in eGFR within 3 months of starting (or increasing the dose of) a renin-angiotensin system antagonist, refractory hypertension, pulmonary oedema, and/or a renal artery bruit)?
Complications of CKD? - Decline in nutritional status or malnutrition? - Persistent hyperkalaemia? - End-stage renal disease (ESRD)? - Renal anaemia? - Renal mineral and bone disease? - Persistent metabolic acidosis? Diagnostic uncertainty? Referral to urologist:
Renal outlfow obstruction?
Signposted to Kidney Care UK: Patient information booklets?
Resource(s): Kidney disease improving global outcomes (KDIGO): 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. April 2024 NICE TA1075: Dapagliflozin for treating chronic kidney disease. July 2025 NICE CKS: Chronic kidney disease. May 2025 Patient/carers: