Chronic Kidney Disease

CKD is an abnormality of kidney structure or function present for at least 3 months with health implications. In routine practice, classify disease by cause, eGFR category, and albuminuria category. A persistently reduced eGFR below 60 mL/min/1.73 m² and/or abnormal albuminuria identifies clinically meaningful CKD; albuminuria can establish CKD despite eGFR of 60 mL/min/1.73 m² or higher. WileyWileyDetecting and managing the patient with chronic kidney ...

Order serum creatinine with laboratory-reported eGFR and spot urine albumin-creatinine ratio (UACR). Creatinine-based eGFR is appropriate first-line testing, but interpret cautiously in sarcopenia, cachexia, amputation, malnutrition, unusually high muscle mass, or drugs that inhibit tubular creatinine secretion, such as trimethoprim. In such settings, creatinine can misrepresent filtration; cystatin C or measured GFR may be useful when an accurate estimate will change a high-stakes decision. WileyWileyDetecting and managing the patient with chronic kidney ...

Albuminuria and eGFR are complementary, not substitutable. Risk rises multiplicatively when both are abnormal, and albuminuria predicts cardiovascular, kidney, and mortality outcomes even with preserved eGFR. Confirm an elevated UACR using an early-morning specimen and evaluate transient causes, including urinary infection, exercise, and blood contamination. WileyWileyDetecting and managing the patient with chronic kidney ...

Blood pressure control and renin-angiotensin-aldosterone system inhibition are central in albuminuric CKD. ACE inhibitors and ARBs reduce proteinuria and are recommended in moderate or severe albuminuria, including in patients without diabetes or hypertension. Do not combine an ACE inhibitor with an ARB or direct renin inhibitor because combined blockade increases adverse events, including acute kidney injury, hypotension, and hyperkalemia. WileyWileyDetecting and managing the patient with chronic kidney ...

After starting or increasing an ACE inhibitor or ARB, reassess creatinine/eGFR and potassium in approximately 2 weeks. A creatinine rise up to 30% or eGFR decline up to 25% may be acceptable if the patient is clinically stable; larger changes should trigger assessment for volume depletion, nonsteroidal anti-inflammatory drug exposure, renovascular disease, obstruction, intercurrent illness, or excessive hemodynamic effect. WileyWileyDetecting and managing the patient with chronic kidney ...

SGLT2 inhibitors reduce kidney disease progression, acute kidney injury, cardiovascular risk, heart-failure hospitalization, and all-cause mortality across CKD populations with and without diabetes. The EMPA-KIDNEY trial demonstrated benefit with empagliflozin in CKD, and evidence syntheses support kidney benefits irrespective of diabetes status. WileyWileyDetecting and managing the patient with chronic kidney ... Product selection, initiation threshold, and dose should follow current FDA labeling because indications and renal thresholds vary by agent. An early, reversible eGFR decline can occur after initiation and does not by itself establish acute kidney injury. WileyWileyDetecting and managing the patient with chronic kidney ...

For type 2 diabetes with albuminuric CKD despite optimized standard therapy, finerenone is an additional evidence-based option. Trials in diabetic CKD found reduced kidney and cardiovascular events, but hyperkalemia requires potassium surveillance. Guideline-based use is as add-on therapy in type 2 diabetes with eGFR above 25 mL/min/1.73 m², albuminuria, normal potassium, and optimized background care. WileyWileyDetecting and managing the patient with chronic kidney ...

Kidney disease changes drug disposition beyond reduced filtration: altered nonrenal clearance, protein binding, volume of distribution, and transporter or metabolic function may contribute to exposure. Dose adjustment is therefore a clinical pharmacology decision, not a mechanical substitution of one kidney-function estimate for another. ScienceDirectScienceDirectDrug dosing consideration in patients with acute and chronic kidney disease—a clinical update from Kidney Disease: Improving Global Outcomes (KDIGO)

For drug dosing, follow the FDA-approved label or authoritative drug-specific source and use the renal-function metric specified for that drug. Many pivotal pharmacokinetic and labeling studies used Cockcroft-Gault creatinine clearance, whereas laboratory eGFR is indexed to 1.73 m² and may produce a different dosing classification, particularly in older adults or those with low body mass. BMJ+1BMJWidespread inappropriate prescribing for older people with reduced kidney function: what are the harms and how do we tackle them? A scoping review for primary care | BMJ Quality & SafetyScienceDirectDrug dosing consideration in patients with acute and chronic kidney disease—a clinical update from Kidney Disease: Improving Global Outcomes (KDIGO)

Acute kidney injury invalidates steady-state assumptions underlying outpatient dosing tables. During dynamic kidney function, reassess doses frequently, prioritize severity-of-illness and therapeutic targets, and use therapeutic drug monitoring when available for narrow-therapeutic-index agents or selected antimicrobials. Dialysis modality, membrane characteristics, session duration, and timing can materially alter drug clearance. ScienceDirect+1ScienceDirectDrug dosing consideration in patients with acute and chronic kidney disease—a clinical update from Kidney Disease: Improving Global Outcomes (KDIGO)ScienceDirectAntibiotic Dosing in Chronic Kidney Disease and End-Stage Renal Disease: A Focus on Contemporary Challenges

Monitor eGFR, UACR, blood pressure, potassium, bicarbonate when clinically relevant, and medication safety parameters at intervals determined by disease severity, progression rate, intercurrent illness, and treatment changes. More frequent surveillance is appropriate after RAAS-inhibitor titration, diuretic changes, hyperkalemia, acute illness, or a decline in kidney function. WileyWileyDetecting and managing the patient with chronic kidney ...

Nephrology referral should be prompted by rapid progression, substantial albuminuria, albuminuria with hematuria, resistant hypertension, suspected genetic or rare kidney disease, possible renal artery stenosis, uncertain cause, or a high predicted risk of kidney failure. The Kidney Failure Risk Equation uses age, sex, eGFR, and UACR to estimate risk and may help align referral with anticipated kidney failure rather than an eGFR threshold alone. WileyWileyDetecting and managing the patient with chronic kidney ...

Interpret prognostic tools in context. Risk equations do not capture all etiologies, biologic variation in eGFR/UACR, competing mortality, frailty, or preferences about kidney replacement therapy. In older adults, treatment and referral should be individualized rather than withheld solely because mild eGFR reduction is age-associated. WileyWileyDetecting and managing the patient with chronic kidney ...