{
  "schemaVersion": 2,
  "eyebrow": "Nephrology",
  "title": "Chronic Kidney Disease",
  "summary": "Chronic kidney disease requires persistent abnormalities in filtration or kidney-damage markers, risk stratification with eGFR and albuminuria, and early use of cardiorenal therapies while avoiding medication-related harm. Management intensity should reflect progression risk, cardiovascular risk, frailty, and patient goals.",
  "seoDescription": "Physician guide to chronic kidney disease diagnosis, risk stratification, cardiorenal therapy, medication safety, monitoring, and referral.",
  "clinicalQuestion": "How should clinicians confirm, stage, risk-stratify, and manage chronic kidney disease while preventing cardiovascular events, progression, and drug-related harm?",
  "specialty": "Nephrology",
  "audience": "U.S. physicians and medical trainees",
  "tags": [
    "chronic kidney disease",
    "CKD",
    "eGFR",
    "albuminuria",
    "UACR",
    "SGLT2 inhibitors",
    "RAAS inhibition",
    "finerenone",
    "kidney failure risk"
  ],
  "keyTakeaways": [
    "Confirm chronicity: CKD requires kidney structural or functional abnormality persisting for at least 3 months; eGFR below 60 mL/min/1.73 m² and/or abnormal albuminuria are central diagnostic markers. [18]",
    "Obtain urine albumin-creatinine ratio with eGFR for risk assessment; risks of kidney failure, cardiovascular events, acute kidney injury, and mortality increase as eGFR falls and albuminuria rises. [18]",
    "For albuminuric CKD, ACE inhibitor or ARB therapy is foundational; check kidney function and potassium after initiation or dose escalation, accepting up to a 30% creatinine rise or 25% eGFR decline when clinically stable. [18]",
    "SGLT2 inhibitors reduce kidney and cardiovascular risk in CKD with and without diabetes; initiate according to product labeling and patient phenotype, recognizing an early reversible eGFR dip may occur. [18]",
    "Medication dosing must account for the specific drug label, renal-function estimator used in its development, dynamic kidney function, and dialysis modality; eGFR alone may not be interchangeable with creatinine clearance for all drugs. [5][19]"
  ],
  "sections": [
    {
      "id": "diagnosis-and-risk-assessment",
      "eyebrow": "Diagnosis",
      "heading": "Confirm CKD and define the risk phenotype",
      "intro": "The initial task is to distinguish chronic disease from acute or reversible kidney dysfunction.",
      "paragraphs": [
        "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. [18]",
        "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. [18]",
        "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. [18]"
      ],
      "bullets": [
        "For a newly identified eGFR below 60 mL/min/1.73 m² without prior data, assess clinical acuity and potential acute kidney injury; if clinically stable, repeat testing promptly and establish persistence over at least 3 months before labeling CKD. [18]",
        "Use urinalysis alongside UACR when glomerular disease, hematuria, or urinary tract pathology is possible. UACR is preferred over total protein-creatinine ratio for low-level albuminuria detection. [18]",
        "Seek an alternative cause rather than assuming diabetes or hypertension when there is rapid decline, active urine sediment, disproportionate proteinuria, systemic disease, family history, or obstructive symptoms. [18]"
      ],
      "subsections": [],
      "table": {
        "caption": "Risk-defining tests in CKD [18]",
        "columns": [
          "Test",
          "Interpretation",
          "Action"
        ],
        "rows": [
          [
            "eGFR",
            "Persistent value below 60 mL/min/1.73 m² supports CKD; trend is more informative than a single result. [18]",
            "Establish chronicity, assess trajectory, and interpret in the context of creatinine generation and acute illness. [18]"
          ],
          [
            "UACR",
            "Albuminuria is abnormal at any level; UACR of 3 mg/mmol or greater is used in international CKD classification. [18]",
            "Confirm with an early-morning sample; use with eGFR for prognosis and treatment selection. [18]"
          ],
          [
            "Urinalysis",
            "Hematuria or active sediment broadens the differential beyond uncomplicated diabetic or hypertensive CKD. [18]",
            "Evaluate for glomerular, urologic, infectious, or structural disease; escalate referral when findings are concerning. [18]"
          ],
          [
            "Kidney ultrasound",
            "Useful when obstruction, structural disease, polycystic kidney disease, advanced CKD, or rapid progression is suspected. [18]",
            "Identify reversible obstruction and structural causes; do not use as a routine test for every stable CKD phenotype. [18]"
          ]
        ]
      }
    },
    {
      "id": "cardiorenal-treatment",
      "eyebrow": "Management",
      "heading": "Use disease-modifying therapy according to albuminuria, diabetes, and heart failure",
      "intro": "Therapy should address kidney progression and cardiovascular risk rather than serum creatinine alone.",
      "paragraphs": [
        "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. [18]",
        "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. [18]",
        "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. [18] 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. [18]",
        "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. [18]"
      ],
      "bullets": [
        "Use either an ACE inhibitor or ARB, not both, in albuminuric CKD. [18]",
        "Check potassium and kidney function after RAAS-inhibitor initiation or titration; mitigate hyperkalemia when possible rather than automatically abandoning disease-modifying therapy. [18]",
        "Counsel patients taking SGLT2 inhibitors to temporarily withhold therapy during acute illness with poor oral intake, vomiting, diarrhea, fever, or planned prolonged fasting, then restart after recovery. [18]",
        "For type 2 diabetes not meeting individualized glycemic targets despite or unable to use metformin and an SGLT2 inhibitor, GLP-1 receptor agonists are recommended by CKD diabetes guidance; titrate gradually because gastrointestinal adverse effects are common. [18]"
      ],
      "subsections": [
        {
          "heading": "Cardiovascular prevention",
          "paragraphs": [
            "CKD confers high cardiovascular risk. Statin-based therapy reduces major vascular events in non-dialysis CKD populations, whereas evidence does not support starting a statin solely for primary prevention after chronic dialysis initiation. Continue or use statins for established atherosclerotic cardiovascular disease as clinically indicated. [18]"
          ],
          "bullets": [
            "Individualize blood-pressure targets in older adults, patients with frailty, orthostasis, falls risk, or limited life expectancy; more intensive targets can increase treatment-related adverse events. [18]"
          ]
        }
      ],
      "table": {
        "caption": "Disease-modifying drug classes in CKD [18]",
        "columns": [
          "Therapy",
          "Best-supported phenotype",
          "Key monitoring or limitation"
        ],
        "rows": [
          [
            "ACE inhibitor or ARB",
            "Albuminuric CKD, especially with diabetes, hypertension, or heart failure. [18]",
            "Check creatinine/eGFR and potassium after initiation or titration; avoid dual RAAS blockade. [18]"
          ],
          [
            "SGLT2 inhibitor",
            "CKD with diabetes or without diabetes, particularly with albuminuria and/or heart failure; follow FDA labeling for the chosen agent. [18]",
            "Expect possible early reversible eGFR dip; provide illness and fasting interruption guidance. [18]"
          ],
          [
            "Finerenone",
            "Type 2 diabetes, albuminuric CKD, appropriate eGFR, normal potassium, and optimized background therapy. [18]",
            "Monitor potassium; hyperkalemia can require interruption and reassessment. [18]"
          ],
          [
            "GLP-1 receptor agonist",
            "Type 2 diabetes with CKD when individualized glycemic goals remain unmet or other preferred therapies cannot be used. [18]",
            "Start low and titrate slowly because gastrointestinal adverse effects are frequent. [18]"
          ]
        ]
      }
    },
    {
      "id": "medication-safety",
      "eyebrow": "Pharmacology",
      "heading": "Prevent drug-related harm through renal-aware prescribing",
      "intro": "Drug safety depends on the medication, the patient, and whether kidney function is stable.",
      "paragraphs": [
        "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. [19]",
        "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. [5][19]",
        "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. [19][21]"
      ],
      "bullets": [
        "Avoid prolonged nonsteroidal anti-inflammatory drug use in CKD and avoid it altogether in advanced CKD when possible; assess concurrent RAAS inhibitor and diuretic exposure, volume status, and alternative analgesic risks. [18]",
        "Review all prescription, over-the-counter, and supplement exposures at CKD diagnosis, after acute illness, and when eGFR or potassium changes. [3][5]",
        "Do not assume that a drug without substantial renal elimination is unaffected by CKD; kidney disease can alter nonrenal drug clearance. [19][20]",
        "For antibiotics in CKD or dialysis, confirm the drug-specific dosing regimen, dialysis timing, and need for therapeutic drug monitoring rather than relying on generic renal-dose rules. [21]"
      ],
      "subsections": [],
      "table": {
        "caption": "Medication-safety checkpoints in CKD [5][19]",
        "columns": [
          "Clinical situation",
          "High-value action"
        ],
        "rows": [
          [
            "Older adult, low muscle mass, or frailty",
            "Recognize creatinine-based eGFR may overestimate kidney function; verify the dosing metric specified in the drug label and consider confirmatory assessment when the consequence of misclassification is high. [5][18]"
          ],
          [
            "New acute illness or acute kidney injury",
            "Reassess medication necessity and dose because renal function is nonsteady-state; do not rely uncritically on chronic CKD dosing tables. [19]"
          ],
          [
            "Hemodialysis, peritoneal dialysis, or continuous kidney replacement therapy",
            "Use modality-specific guidance; extracorporeal clearance and dosing timing vary by therapy and drug characteristics. [19][21]"
          ],
          [
            "Polypharmacy",
            "Perform structured medication review for dosing, nephrotoxins, interactions, and duplicate therapies. Inappropriate renal prescribing is common among older adults with reduced kidney function. [5]"
          ]
        ]
      }
    },
    {
      "id": "monitoring-and-referral",
      "eyebrow": "Follow-up",
      "heading": "Monitor progression and refer based on trajectory, urine findings, and kidney-failure risk",
      "intro": "Follow-up intensity should increase with lower eGFR, higher albuminuria, and clinical instability.",
      "paragraphs": [
        "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. [18]",
        "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. [18]",
        "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. [18]"
      ],
      "bullets": [
        "Urgently evaluate new nephrotic syndrome, rapidly falling eGFR, suspected obstruction, severe hyperkalemia, uremic symptoms, or systemic features suggesting glomerulonephritis or vasculitis. [18]",
        "Refer for UACR of 70 mg/mmol or greater, or UACR above 30 mg/mmol with hematuria, unless an established cause and appropriate treatment make specialist input unnecessary; these are international, not U.S.-specific, thresholds. [18]",
        "Consider referral for sustained eGFR decline of at least 25% with a GFR-category change within 12 months or sustained decline of at least 15 mL/min/1.73 m² per year. [18]"
      ],
      "subsections": [],
      "table": {
        "caption": "Findings that should accelerate nephrology involvement [18]",
        "columns": [
          "Finding",
          "Why it matters"
        ],
        "rows": [
          [
            "Rapid eGFR decline",
            "May indicate active, potentially treatable disease or accelerated progression requiring etiologic evaluation. [18]"
          ],
          [
            "Albuminuria with hematuria",
            "Raises concern for glomerular pathology and warrants specialist assessment. [18]"
          ],
          [
            "Heavy albuminuria",
            "Identifies high cardiorenal risk and may require additional diagnostic and therapeutic intervention. [18]"
          ],
          [
            "Resistant hypertension",
            "May signal secondary causes, volume-mediated hypertension, or need for specialized treatment. [18]"
          ],
          [
            "High kidney-failure risk estimate",
            "Supports timely education, nephrology care, and planning while accounting for competing risks and patient preferences. [18]"
          ]
        ]
      }
    }
  ],
  "faq": [
    {
      "question": "Should drug dosing in CKD use eGFR or Cockcroft-Gault creatinine clearance?",
      "answer": "Use the kidney-function metric specified in the FDA label or drug-specific evidence base. Many drug studies used Cockcroft-Gault creatinine clearance, while laboratory eGFR is indexed to 1.73 m² and may classify older or low-body-mass patients differently. [5][19]"
    },
    {
      "question": "When should an ACE inhibitor or ARB be stopped after creatinine rises?",
      "answer": "A creatinine increase up to 30% or eGFR decline up to 25% after initiation or dose escalation may be acceptable if the patient is clinically stable. Larger changes require evaluation for hemodynamic or reversible causes and reassessment of therapy. [18]"
    },
    {
      "question": "Does an early eGFR decline after SGLT2 inhibitor initiation require discontinuation?",
      "answer": "No. A small reversible eGFR dip is expected after SGLT2 inhibitor initiation and should not alone be interpreted as acute kidney injury or trigger discontinuation without other adverse features. [18]"
    },
    {
      "question": "Which CKD patients need UACR testing?",
      "answer": "UACR should be measured with eGFR to diagnose and risk-stratify CKD, especially in diabetes, hypertension, cardiovascular disease, prior acute kidney injury, and suspected kidney disease. Albuminuria changes prognosis and guides use of RAAS inhibition and SGLT2 inhibitors. [18]"
    }
  ],
  "references": [
    {
      "number": 1,
      "title": "- IIER - accessdata.fda.gov",
      "detail": "www.accessdata.fda.gov",
      "url": "https://www.accessdata.fda.gov/drugsatfda_docs/label/2026/219962Orig1s000Lbl.pdf",
      "authors": "www.accessdata.fda.gov",
      "host": "www.accessdata.fda.gov"
    },
    {
      "number": 2,
      "title": "FDA Drug Safety Communication: Modified dosing recommendations to improve the safe use of Erythropoiesis-Stimulating Agents (ESAs) in chronic kidney disease | FDA",
      "detail": "www.fda.gov",
      "url": "https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-modified-dosing-recommendations-improve-safe-use-erythropoiesis",
      "authors": "www.fda.gov",
      "host": "www.fda.gov"
    },
    {
      "number": 3,
      "title": "Acute kidney injury - References",
      "detail": "bestpractice.bmj.com",
      "url": "https://bestpractice.bmj.com/topics/en-us/83/references",
      "authors": "bestpractice.bmj.com",
      "host": "bestpractice.bmj.com"
    },
    {
      "number": 4,
      "title": "BMJ Rapid Recommendations | The BMJ",
      "detail": "www.bmj.com",
      "url": "https://www.bmj.com/rapid-recommendations",
      "authors": "www.bmj.com",
      "host": "www.bmj.com"
    },
    {
      "number": 5,
      "title": "Widespread 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 & Safety",
      "detail": "qualitysafety.bmj.com",
      "url": "https://qualitysafety.bmj.com/content/early/2025/10/07/bmjqs-2025-018736?versioned=true",
      "authors": "qualitysafety.bmj.com",
      "host": "qualitysafety.bmj.com"
    },
    {
      "number": 6,
      "title": "Accounting for Age in the Definition of Chronic Kidney ...",
      "detail": "jamanetwork.com",
      "url": "https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2783456",
      "authors": "jamanetwork.com",
      "host": "jamanetwork.com"
    },
    {
      "number": 7,
      "title": "Strategies for managing chronic kidney disease",
      "detail": "www.thelancet.com",
      "url": "https://www.thelancet.com/do-content/ckd",
      "authors": "www.thelancet.com",
      "host": "www.thelancet.com"
    },
    {
      "number": 8,
      "title": "Dose adjustment in renal impairment: Response from Drug Prescribing in Renal Failure",
      "detail": "www.bmj.com",
      "url": "https://www.bmj.com/content/331/7511/293.2",
      "authors": "www.bmj.com",
      "host": "www.bmj.com"
    },
    {
      "number": 9,
      "title": "Developing Guidelines for Chronic Kidney Disease: We Should Include All of the Outcomes | Annals of Internal Medicine",
      "detail": "www.acpjournals.org",
      "url": "https://www.acpjournals.org/doi/10.7326/0003-4819-156-8-201204170-00012",
      "authors": "www.acpjournals.org",
      "host": "www.acpjournals.org"
    },
    {
      "number": 10,
      "title": "Screening for Chronic Kidney Disease: U.S. Preventive ...",
      "detail": "www.acpjournals.org",
      "url": "https://www.acpjournals.org/doi/10.7326/0003-4819-157-8-201210160-00533",
      "authors": "www.acpjournals.org",
      "host": "www.acpjournals.org"
    },
    {
      "number": 11,
      "title": "Screening, Monitoring, and Treatment of Stage 1 to 3 ...",
      "detail": "www.acpjournals.org",
      "url": "https://www.acpjournals.org/doi/10.7326/0003-4819-159-12-201312170-00726",
      "authors": "www.acpjournals.org",
      "host": "www.acpjournals.org"
    },
    {
      "number": 12,
      "title": "Diabetes Management in Chronic Kidney Disease",
      "detail": "www.acpjournals.org",
      "url": "https://www.acpjournals.org/doi/10.7326/M20-5938",
      "authors": "www.acpjournals.org",
      "host": "www.acpjournals.org"
    },
    {
      "number": 13,
      "title": "KDIGO 2024 clinical practice guideline on evaluation and ...",
      "detail": "academic.oup.com",
      "url": "https://academic.oup.com/ajhp/article/82/12/660/8107680",
      "authors": "academic.oup.com",
      "host": "academic.oup.com"
    },
    {
      "number": 14,
      "title": "Updates in chronic kidney disease management: A systematic ...",
      "detail": "accpjournals.onlinelibrary.wiley.com",
      "url": "https://accpjournals.onlinelibrary.wiley.com/doi/10.1002/phar.70014",
      "authors": "accpjournals.onlinelibrary.wiley.com",
      "host": "accpjournals.onlinelibrary.wiley.com"
    },
    {
      "number": 15,
      "title": "Pro: Thresholds to define chronic kidney disease should not ...",
      "detail": "academic.oup.com",
      "url": "https://academic.oup.com/ndt/article/29/4/770/1929237",
      "authors": "academic.oup.com",
      "host": "academic.oup.com"
    },
    {
      "number": 16,
      "title": "Risk-based versus GFR threshold criteria for nephrology ...",
      "detail": "academic.oup.com",
      "url": "https://academic.oup.com/ckj/article/15/11/1996/6571261",
      "authors": "academic.oup.com",
      "host": "academic.oup.com"
    },
    {
      "number": 17,
      "title": "Evolving strategies for early diagnosis, proactive prevention ...",
      "detail": "academic.oup.com",
      "url": "https://academic.oup.com/ndt/article/41/3/418/8228479",
      "authors": "academic.oup.com",
      "host": "academic.oup.com"
    },
    {
      "number": 18,
      "title": "Detecting and managing the patient with chronic kidney ...",
      "detail": "dom-pubs.onlinelibrary.wiley.com",
      "url": "https://dom-pubs.onlinelibrary.wiley.com/doi/10.1111/dom.15625",
      "authors": "dom-pubs.onlinelibrary.wiley.com",
      "host": "dom-pubs.onlinelibrary.wiley.com"
    },
    {
      "number": 19,
      "title": "Drug dosing consideration in patients with acute and chronic kidney disease—a clinical update from Kidney Disease: Improving Global Outcomes (KDIGO)",
      "detail": "www.sciencedirect.com",
      "url": "https://www.sciencedirect.com/science/article/pii/S0085253815549843",
      "authors": "www.sciencedirect.com",
      "host": "www.sciencedirect.com"
    },
    {
      "number": 20,
      "title": "Evaluation of Exposure Change of Nonrenally Eliminated ...",
      "detail": "accp1.onlinelibrary.wiley.com",
      "url": "https://accp1.onlinelibrary.wiley.com/doi/10.1177/0091270011415528",
      "authors": "accp1.onlinelibrary.wiley.com",
      "host": "accp1.onlinelibrary.wiley.com"
    },
    {
      "number": 21,
      "title": "Antibiotic Dosing in Chronic Kidney Disease and End-Stage Renal Disease: A Focus on Contemporary Challenges",
      "detail": "www.sciencedirect.com",
      "url": "https://www.sciencedirect.com/science/article/abs/pii/S1548559518302192",
      "authors": "www.sciencedirect.com",
      "host": "www.sciencedirect.com"
    },
    {
      "number": 22,
      "title": "Influence of kidney disease on drug disposition: An ...",
      "detail": "accp1.onlinelibrary.wiley.com",
      "url": "https://accp1.onlinelibrary.wiley.com/doi/10.1002/jcph.604",
      "authors": "accp1.onlinelibrary.wiley.com",
      "host": "accp1.onlinelibrary.wiley.com"
    },
    {
      "number": 23,
      "title": "Cancer Drug Dosing in Chronic Kidney Disease and Dialysis - ScienceDirect",
      "detail": "www.sciencedirect.com",
      "url": "https://www.sciencedirect.com/science/article/abs/pii/S1548559521001671",
      "authors": "www.sciencedirect.com",
      "host": "www.sciencedirect.com"
    },
    {
      "number": 24,
      "title": "Renal drug dosing recommendations: evaluation of ...",
      "detail": "onlinelibrary.wiley.com",
      "url": "https://onlinelibrary.wiley.com/doi/10.1111/imj.12446",
      "authors": "onlinelibrary.wiley.com",
      "host": "onlinelibrary.wiley.com"
    }
  ],
  "editorialNote": "Prepared from cited clinical literature using Astra's research workflow. Verify recommendations against current guidance and patient-specific factors.",
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    {
      "number": 1,
      "title": "- IIER - accessdata.fda.gov",
      "detail": "www.accessdata.fda.gov",
      "url": "https://www.accessdata.fda.gov/drugsatfda_docs/label/2026/219962Orig1s000Lbl.pdf",
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      "title": "FDA Drug Safety Communication: Modified dosing recommendations to improve the safe use of Erythropoiesis-Stimulating Agents (ESAs) in chronic kidney disease | FDA",
      "detail": "www.fda.gov",
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      "title": "Acute kidney injury - References",
      "detail": "bestpractice.bmj.com",
      "url": "https://bestpractice.bmj.com/topics/en-us/83/references",
      "authors": "bestpractice.bmj.com",
      "host": "bestpractice.bmj.com",
      "snippet": "210.Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2024 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int. 2024 Apr;105(4s):S117-S314.Full textAbstract\n\n211.National Institute for Health and Care Excellence. Acute kidney inju",
      "score": 0.59655124
    },
    {
      "number": 4,
      "title": "BMJ Rapid Recommendations | The BMJ",
      "detail": "www.bmj.com",
      "url": "https://www.bmj.com/rapid-recommendations",
      "authors": "www.bmj.com",
      "host": "www.bmj.com",
      "snippet": "The BMJ Practice: Sodium-glucose cotransporter-2 (SGLT-2) inhibitors for adults with chronic kidney disease: a clinical practice guideline\n\nBMJ Medicine research: Sodium-glucose co-transporter-2 inhibitors in patients with chronic kidney disease with or without type 2 diabetes: systematic review and",
      "score": 0.43295085
    },
    {
      "number": 5,
      "title": "Widespread 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 & Safety",
      "detail": "qualitysafety.bmj.com",
      "url": "https://qualitysafety.bmj.com/content/early/2025/10/07/bmjqs-2025-018736?versioned=true",
      "authors": "qualitysafety.bmj.com",
      "host": "qualitysafety.bmj.com",
      "snippet": "57 60 66 expert opinions (n=8, 19%),28 34 35 39 54 59 62 67 Lexicomp (n=4, 9%),42 43 46 64 or did not state a guideline (n=3, 7%).38 41 49 The Cockcroft-Gault formula was used to estimate GFR in 14 studies (n=33%),12 31 37 40–42 45–47 50 52 60 62 65 while other studies used MDRD (n=11, 26%),25 27 29",
      "score": 0.32126883
    },
    {
      "number": 6,
      "title": "Accounting for Age in the Definition of Chronic Kidney ...",
      "detail": "jamanetwork.com",
      "url": "https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2783456",
      "authors": "jamanetwork.com",
      "host": "jamanetwork.com",
      "snippet": "by P Liu · 2021 · Cited by 205 — An age-adapted CKD definition has been proposed, with eGFR thresholds of 75, 60, and 45 mL/min/1.73 m2 for younger than 40, 40 to 64, and 65",
      "score": 0.6044228
    },
    {
      "number": 7,
      "title": "Strategies for managing chronic kidney disease",
      "detail": "www.thelancet.com",
      "url": "https://www.thelancet.com/do-content/ckd",
      "authors": "www.thelancet.com",
      "host": "www.thelancet.com",
      "snippet": "The Lancet Seminar on chronic kidney disease highlights strategies for management, from kidney-preserving care to supportive care.",
      "score": 0.30716103
    },
    {
      "number": 8,
      "title": "Dose adjustment in renal impairment: Response from Drug Prescribing in Renal Failure",
      "detail": "www.bmj.com",
      "url": "https://www.bmj.com/content/331/7511/293.2",
      "authors": "www.bmj.com",
      "host": "www.bmj.com",
      "snippet": "EDITOR—Vidal et al should be congratulated on the first scholarly, systematic review of secondary sources of prescribing information for patients with impaired renal function (p 263).1 That they found inconsistent and conflicting recommendations across multiple sources is not surprising. Their work ",
      "score": 0.38193452
    },
    {
      "number": 9,
      "title": "Developing Guidelines for Chronic Kidney Disease: We Should Include All of the Outcomes | Annals of Internal Medicine",
      "detail": "www.acpjournals.org",
      "url": "https://www.acpjournals.org/doi/10.7326/0003-4819-156-8-201204170-00012",
      "authors": "www.acpjournals.org",
      "host": "www.acpjournals.org",
      "snippet": "PubMed\n\nGoogle Scholar\n\n11.\n\nKidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO clinical practice guideline for acute kidney injury. Kidney International Supplements. 2012;2:1-138.\n\nGoogle Scholar\n\n12.\n\nFink HA, Ishani A, Taylor BC, Greer NL, MacDonald R, Rossini",
      "score": 0.7734393
    },
    {
      "number": 10,
      "title": "Screening for Chronic Kidney Disease: U.S. Preventive ...",
      "detail": "www.acpjournals.org",
      "url": "https://www.acpjournals.org/doi/10.7326/0003-4819-157-8-201210160-00533",
      "authors": "www.acpjournals.org",
      "host": "www.acpjournals.org",
      "snippet": "by VA Moyer · 2012 · Cited by 235 — Diagnosis and management of non-dialysis chronic kidney disease in ambulatory care: a systematic review of clinical practice guidelines.",
      "score": 0.6490677
    },
    {
      "number": 11,
      "title": "Screening, Monitoring, and Treatment of Stage 1 to 3 ...",
      "detail": "www.acpjournals.org",
      "url": "https://www.acpjournals.org/doi/10.7326/0003-4819-159-12-201312170-00726",
      "authors": "www.acpjournals.org",
      "host": "www.acpjournals.org",
      "snippet": "by A Qaseem · Cited by 288 — This American College of Physicians (ACP) guideline presents available evidence on the screening, monitoring, and treatment of stage 1 to 3 CKD.",
      "score": 0.5596998
    },
    {
      "number": 12,
      "title": "Diabetes Management in Chronic Kidney Disease",
      "detail": "www.acpjournals.org",
      "url": "https://www.acpjournals.org/doi/10.7326/M20-5938",
      "authors": "www.acpjournals.org",
      "host": "www.acpjournals.org",
      "snippet": "by SD Navaneethan · 2021 · Cited by 201 — Clinical Guidelines. 10 November 2020. Diabetes Management in Chronic Kidney Disease: Synopsis of the 2020 KDIGO Clinical Practice Guideline.",
      "score": 0.5501488
    },
    {
      "number": 13,
      "title": "KDIGO 2024 clinical practice guideline on evaluation and ...",
      "detail": "academic.oup.com",
      "url": "https://academic.oup.com/ajhp/article/82/12/660/8107680",
      "authors": "academic.oup.com",
      "host": "academic.oup.com",
      "snippet": "by L Awdishu · 2025 · Cited by 56 — The updated guideline includes refinement of kidney function estimation, population and individual risk prediction, and novel treatments",
      "score": 0.3485348
    },
    {
      "number": 14,
      "title": "Updates in chronic kidney disease management: A systematic ...",
      "detail": "accpjournals.onlinelibrary.wiley.com",
      "url": "https://accpjournals.onlinelibrary.wiley.com/doi/10.1002/phar.70014",
      "authors": "accpjournals.onlinelibrary.wiley.com",
      "host": "accpjournals.onlinelibrary.wiley.com",
      "snippet": "This systematic review aims to evaluate the efficacy and safety of emerging therapeutic strategies for CKD management, including sodium-glucose",
      "score": 0.27835777
    },
    {
      "number": 15,
      "title": "Pro: Thresholds to define chronic kidney disease should not ...",
      "detail": "academic.oup.com",
      "url": "https://academic.oup.com/ndt/article/29/4/770/1929237",
      "authors": "academic.oup.com",
      "host": "academic.oup.com",
      "snippet": "by G Conte · 2014 · Cited by 19 — Current thresholds to define chronic kidney disease (CKD) are essentially based on two measures, estimated GFR (eGFR) and albuminuria. The first two stages.",
      "score": 0.68697983
    },
    {
      "number": 16,
      "title": "Risk-based versus GFR threshold criteria for nephrology ...",
      "detail": "academic.oup.com",
      "url": "https://academic.oup.com/ckj/article/15/11/1996/6571261",
      "authors": "academic.oup.com",
      "host": "academic.oup.com",
      "snippet": "by N Oliva-Damaso · 2022 · Cited by 38 — Most referral guidelines for CKD limit the attention to when eGFR is consistently <30 mL/min/1.73 m2 and the likelihood of kidney replacement therapy is",
      "score": 0.45856747
    },
    {
      "number": 17,
      "title": "Evolving strategies for early diagnosis, proactive prevention ...",
      "detail": "academic.oup.com",
      "url": "https://academic.oup.com/ndt/article/41/3/418/8228479",
      "authors": "academic.oup.com",
      "host": "academic.oup.com",
      "snippet": "by A Ortiz · 2026 · Cited by 20 — CKD is defined by a decrease in eGFR to levels <60 ml/min/1.73 m2 or by the presence of markers of kidney damage such as albuminuria, urine sediment",
      "score": 0.28896067
    },
    {
      "number": 18,
      "title": "Detecting and managing the patient with chronic kidney ...",
      "detail": "dom-pubs.onlinelibrary.wiley.com",
      "url": "https://dom-pubs.onlinelibrary.wiley.com/doi/10.1111/dom.15625",
      "authors": "dom-pubs.onlinelibrary.wiley.com",
      "host": "dom-pubs.onlinelibrary.wiley.com",
      "snippet": "There is little to no evidence to support clear guidelines for the frequency of monitoring in CKD. UK guidelines recommend a minimum frequency for monitoring according to the severity of eGFR and albuminuria abnormalities (Table2); however, more frequent monitoring may be required in those with a fa",
      "score": 0.75659186
    },
    {
      "number": 19,
      "title": "Drug dosing consideration in patients with acute and chronic kidney disease—a clinical update from Kidney Disease: Improving Global Outcomes (KDIGO)",
      "detail": "www.sciencedirect.com",
      "url": "https://www.sciencedirect.com/science/article/pii/S0085253815549843",
      "authors": "www.sciencedirect.com",
      "host": "www.sciencedirect.com",
      "snippet": "Drug dosage adjustment for patients with acute or chronic kidney disease is an accepted standard of practice. The challenge is how to accurately estimate a patient’s kidney function in both acute and chronic kidney disease and determine the influence of renal replacement therapies on drug dispositio",
      "score": 0.5101799
    },
    {
      "number": 20,
      "title": "Evaluation of Exposure Change of Nonrenally Eliminated ...",
      "detail": "accp1.onlinelibrary.wiley.com",
      "url": "https://accp1.onlinelibrary.wiley.com/doi/10.1177/0091270011415528",
      "authors": "accp1.onlinelibrary.wiley.com",
      "host": "accp1.onlinelibrary.wiley.com",
      "snippet": "Chronic kidney disease, known as renal impairment, may affect drug exposure in patients and may require appropriate dose adjustments.1,2",
      "score": 0.444493
    },
    {
      "number": 21,
      "title": "Antibiotic Dosing in Chronic Kidney Disease and End-Stage Renal Disease: A Focus on Contemporary Challenges",
      "detail": "www.sciencedirect.com",
      "url": "https://www.sciencedirect.com/science/article/abs/pii/S1548559518302192",
      "authors": "www.sciencedirect.com",
      "host": "www.sciencedirect.com",
      "snippet": "the many patterns of antibiotic-associated toxicity and the mechanism by which adverse effects occur can enable the development of effective strategies for dealing with these effects. The consideration with antibiotic-induced toxicity may deal with the events after it occurred; however, the most val",
      "score": 0.43093804
    },
    {
      "number": 22,
      "title": "Influence of kidney disease on drug disposition: An ...",
      "detail": "accp1.onlinelibrary.wiley.com",
      "url": "https://accp1.onlinelibrary.wiley.com/doi/10.1002/jcph.604",
      "authors": "accp1.onlinelibrary.wiley.com",
      "host": "accp1.onlinelibrary.wiley.com",
      "snippet": "The FDA-APIs provided dosage information for patients with renal impairment for 95.7% of NCEs that had a renal PK study done (Table 3).",
      "score": 0.36990723
    },
    {
      "number": 23,
      "title": "Cancer Drug Dosing in Chronic Kidney Disease and Dialysis - ScienceDirect",
      "detail": "www.sciencedirect.com",
      "url": "https://www.sciencedirect.com/science/article/abs/pii/S1548559521001671",
      "authors": "www.sciencedirect.com",
      "host": "www.sciencedirect.com",
      "snippet": "# Review Article Cancer Drug Dosing in Chronic Kidney Disease and Dialysis. Patients with malignancies have a high prevalence of kidney disease and are often treated with antineoplastic agents that undergo kidney metabolism or excretion or clearance via renal replacement therapies. Thus, the dosing ",
      "score": 0.30912846
    },
    {
      "number": 24,
      "title": "Renal drug dosing recommendations: evaluation of ...",
      "detail": "onlinelibrary.wiley.com",
      "url": "https://onlinelibrary.wiley.com/doi/10.1111/imj.12446",
      "authors": "onlinelibrary.wiley.com",
      "host": "onlinelibrary.wiley.com",
      "snippet": "The Monthly Index of Medical Specialities (MIMS) was examined for 28 generic drugs recommended to be used with caution in renal impairment. For",
      "score": 0.27051288
    }
  ],
  "publishedAt": "2026-08-20T23:38:38.765165Z",
  "updatedAt": "2026-08-20T23:38:38.765165Z",
  "readingMinutes": 6,
  "slug": "chronic-kidney-disease"
}