Diagnostic criteria (NICE CG182)
CKD is defined by EITHER (or both) present for >90 days:
eGFR <60
ml/min/1.73m² — confirmed on TWO readings ≥90 days apart
ACR ≥3 mg/mmol
On at least 2 of 3 samples — exclude UTI, menstruation, vigorous exercise
!eGFR 60–89 alone does NOT diagnose CKD unless a structural abnormality, haematuria, or additional risk marker is present. Document as "reduced eGFR — monitor".
iAlways confirm with a repeat eGFR ≥90 days after the initial abnormal result to exclude AKI.
ACR Categories
| Category | ACR (mg/mmol) | Description | Dipstick | Action |
|---|
| A1 | <3 | Normal to mildly increased | Negative/trace | Reassure; annual check if risk factors |
| A2 | 3–30 | Moderately increased | + (1+) | Confirm CKD; ACEi/ARB if DM or HT |
| A3 | >30 | Severely increased | ++ or more | Nephrology if non-diabetic ACR >70 |
Use early morning urine. ACR preferred over PCR. PCR >50 mg/mmol ≈ ACR >30 mg/mmol.
Other markers establishing CKD diagnosis
- Persistent haematuria (non-urological) — exclude malignancy first, then nephrology
- Structural abnormalities: polycystic kidneys, reflux nephropathy, single kidney
- Electrolyte disorders from renal tubular disease
- Renal biopsy-proven glomerulonephritis or tubulointerstitial nephritis
eGFR Staging (KDIGO / NICE CG182)
| Stage | eGFR (ml/min/1.73m²) | Description | Monitoring | Key action |
|---|
| G1 | ≥90 | Normal or high | Annual if markers | Only CKD if additional markers |
| G2 | 60–89 | Mildly decreased | Annual if markers | Only CKD if markers; document trend |
| G3a | 45–59 | Mildly–moderately decreased | 6–12 monthly | Optimise BP, lipids, DM, lifestyle |
| G3b | 30–44 | Moderately–severely decreased | 3–6 monthly | PTH/Ca/PO₄ monitoring; anaemia screen |
| G4 | 15–29 | Severely decreased | 3 monthly | Refer nephrology; begin RRT/conservative planning |
| G5 | <15 | Kidney failure | Monthly | RRT or conservative pathway; specialist care |
KDIGO Risk Heat Map (monitoring frequency per year)
Shading: low (green) → very high risk (dark red)
eGFR Stage
A1 — <3 mg/mmol
A2 — 3–30 mg/mmol
A3 — >30 mg/mmol
G1 (≥90)
Low — 1×
Moderate — 1×
High — 1×
G2 (60–89)
Low — 1×
Moderate — 1×
High — 1×
G3a (45–59)
Moderate — 1×
High — 1×
Very high — 2×
G3b (30–44)
High — 1×
Very high — 2×
Very high — 2×
G4 (15–29)
Very high — 3×
Very high — 3×
Refer — 3–4×
G5 (<15)
Refer — 4+×
Refer — 4+×
Refer — 4+×
Rapid Progression
!Refer to nephrology if: sustained decline >5 ml/min/1.73m² within 1 year, OR >10 ml/min/1.73m² within 5 years — regardless of absolute eGFR.
- Calculate rate from ≥3 eGFR readings over ≥18 months for reliability (use trajectory calculator)
- Consider AKI-on-CKD, obstructive uropathy, or renovascular disease as causes
- Review nephrotoxic agents: NSAIDs, aminoglycosides, iodinated contrast, lithium
Blood Pressure Targets in CKD (NICE NG136 / CG182)
No diabetes — ACR <70 mg/mmol
≤140/90 mmHg
Clinic BP (or ≤135/85 on ABPM/home monitoring)
- Offer ACEi or ARB if ACR ≥30 mg/mmol — regardless of BP level
- If ACR <30 (non-proteinuric): treat as standard HT — A/C/D pathway
- Do NOT combine ACEi + ARB (ONTARGET: increased AKI and hyperkalaemia)
No diabetes — ACR ≥70 mg/mmol (heavy proteinuria)
≤130/80 mmHg
Lower target — high CV and progression risk
- ACEi or ARB mandatory first-line
- Up-titrate to maximum tolerated dose before adding second agent
- Likely non-diabetic GN — consider nephrology referral
With diabetes (T1DM or T2DM)
≤130/80 mmHg
Tighter target regardless of ACR level
- ACEi or ARB first-line in all diabetic CKD
- ACEi preferred in T1DM with nephropathy (evidence base)
- ARB (e.g. losartan) preferred in T2DM with nephropathy (RENAAL/IDNT)
Established CVD
≤130/80 mmHg
Tighter target for secondary prevention
- ACEi or ARB first-line regardless of proteinuria level
- Add CCB (amlodipine) as step 2 for BP control
- Thiazide-like diuretic (indapamide) as step 3
SADMAN — Sick Day Rules (CKD G3b+)
!Hold SADMAN drugs during acute illness (vomiting, diarrhoea, dehydration, high fever) and resume when eating and drinking normally for 24–48 hours.
| Letter | Drug class | Why hold |
|---|
| S | Sulfonylureas | Hypoglycaemia risk when not eating |
| A | ACE inhibitors | AKI risk during volume depletion |
| D | Diuretics | Exacerbate volume depletion |
| M | Metformin | Lactic acidosis risk |
| A | ARBs | AKI risk during volume depletion |
| N | NSAIDs | AKI risk; nephrotoxic in CKD |
Statin Therapy in CKD (NICE NG238)
| Patient group | Indication | Suggested statin | Non-HDL-C target |
|---|
| Established CVD (any) | Offer — secondary prevention | Atorvastatin 80mg (40mg if not tolerated) | <2.6 mmol/L |
| T2DM age ≥40 | Offer | Atorvastatin 20mg | <3.4 mmol/L |
| T1DM age ≥40 | Offer | Atorvastatin 20mg | <3.4 mmol/L |
| CKD G3a+ (no DM/CVD) | Consider after discussion | Atorvastatin 20mg | <3.4 mmol/L |
| QRISK3 ≥10% | Offer | Atorvastatin 20mg | <3.4 mmol/L |
| T1/T2DM age <40 | Consider (not automatic offer) | Atorvastatin 20mg | Assess risk |
Suggested doses as per NICE NG238. Prescribing decision and dose remain with the clinician.
Monitoring targets
<2.6 mmol/L
Non-HDL-C — secondary prevention target
<3.4 mmol/L
Non-HDL-C — primary prevention target
- Check fasting lipids 3 months after initiation or dose change
- If non-HDL-C above target on high-intensity statin: add ezetimibe 10mg
- Myopathy risk: check CK if muscle symptoms. Statin-induced myopathy rare but serious.
- Avoid gemfibrozil with statin (increased myopathy risk)
Management by CKD Stage
| Stage | Priorities | Additional monitoring |
|---|
| G1–G2 | Treat underlying cause; BP control; lifestyle; ACEi/ARB if proteinuric/DM; statins | Annual U&E, eGFR, ACR, BP, lipids, HbA1c if DM |
| G3a | As above + anaemia screen; SGLT2i review; sick day rules education | 6–12 monthly; add Hb |
| G3b | As above + bone mineral disease screening; SADMAN rules; conservative medication review | 3–6 monthly; add PTH, Ca, PO₄, HCO₃, iron studies |
| G4 | Nephrology referral; RRT planning; Hep B vaccination; conservative planning discussion | 3 monthly; full renal panel, FBC + Hep B serology |
| G5 | Specialist care; RRT or conservative pathway; fluid and electrolyte management | Monthly; U&E, FBC, PO₄, Ca, HCO₃, fluid status |
Metformin in CKD (NICE CG182)
!Caution when eGFR 30–44 ml/min — review dose and monitor closely. Stop when eGFR <30 ml/min — risk of lactic acidosis.
- Metformin should not be used during acute illness or iodinated contrast procedures if eGFR <60
- Resume 48 hours after contrast or resolution of acute illness if eGFR stable
Potassium management with RASi
| K⁺ level | Action |
|---|
| <5.5 mmol/L | Continue ACEi/ARB at current dose |
| 5.5–6.0 mmol/L | Caution — dietary K⁺ restriction; review ACEi/ARB dose; recheck in 2–4 weeks |
| >6.0 mmol/L | Withhold ACEi/ARB; urgent clinical review; consider patiromer or sodium zirconium; restart when K⁺ <5.5 mmol/L |
NICE Nephrology Referral Criteria (CG182)
| Criterion | Threshold | Urgency |
|---|
| eGFR | <30 ml/min/1.73m² | Refer |
| eGFR | <15 ml/min/1.73m² | Urgent — RRT planning |
| ACR | ≥300 mg/mmol (nephrotic range) | Urgent |
| ACR + low eGFR | ≥70 mg/mmol + eGFR <45 | Refer |
| Rapid decline | >5 ml/min/yr | Refer |
| Haematuria | Persistent, non-urological | Refer |
| Suspected GN | Any stage | Refer |
Monitoring Frequency by Stage (NICE CG182 Table 4)
| Stage | Frequency | Core tests |
|---|
| G1–G2 | Annually | U&E, eGFR, ACR, BP, HbA1c if DM, lipids |
| G3a | Every 6–12 months | As above + Hb |
| G3b | Every 3–6 months | As above + PTH, Ca, PO₄, HCO₃, iron studies |
| G4 | Every 3 months | Full renal panel, FBC, iron studies, PTH, Ca, PO₄, HCO₃ + Hep B serology |
| G5 | Monthly | U&E, FBC, PO₄, Ca, HCO₃, fluid status |
SGLT2 Inhibitors in CKD (NICE TA739)
Dapagliflozin 10mg once daily — NICE TA739 criteria
| Criterion | Threshold |
|---|
| eGFR | ≥20 ml/min/1.73m² |
| ACR | ≥22 mg/mmol (≈200 mg/g) |
| RASi | On maximum tolerated ACEi or ARB |
| Diabetes type | Not T1DM (DKA risk — not NICE-approved for CKD indication) |
Suggested doses as per NICE TA739. Prescribing decision and dose remain with the clinician.
Practical prescribing notes
- Expected eGFR dip of ~3–5 ml/min in first 4 weeks — haemodynamic, not harmful. Do not stop.
- Stop if eGFR falls below 20 ml/min (loss of glycaemic efficacy below this threshold)
- Counsel on genital mycotic infection (especially women): good hygiene; treat with topical antifungal
- Sick day rules: hold dapagliflozin during acute illness (DKA risk) — include in SADMAN education
- Recheck eGFR and K⁺ at 4–6 weeks after starting, then per CKD stage monitoring frequency
- No dose adjustment needed for hepatic impairment; avoid in severe hepatic impairment
DAPA-CKD trial summary
✓DAPA-CKD (NEJM 2020): Dapagliflozin 10mg reduced the composite of ≥50% sustained eGFR decline, ESKD, or renal/CV death by 39% vs placebo (HR 0.61, 95% CI 0.51–0.72). Benefit was consistent across diabetic and non-diabetic CKD.