Managing Chronic Kidney Disease

Documents to Request

• eGFR trend (minimum 3 values over 12 months for trajectory analysis)
• UACR trend (minimum 2 values to confirm persistence)
• Comprehensive metabolic panel with bicarbonate
• Phosphorus, intact PTH, 25-OH vitamin D
• CBC with hemoglobin trend
• Lipid panel
• Urinalysis with microscopy
• Renal ultrasound (if not previously obtained)
• Hepatitis B/C serology (if not previously tested)
• Current medication list annotated with renal clearance considerations

Step 1: CKD Staging and Risk Classification

KDIGO GFR Categories:

KDIGO Albuminuria Categories:

Risk classification uses the GxAx matrix to determine monitoring frequency and referral urgency. Higher GFR stage + higher albuminuria = higher risk of progression.

CKD-EPI 2021 equation (race-neutral): mandatory per NKF/ASN joint statement. Do NOT use race-based eGFR.

Step 2: Slowing Progression — Core Interventions

eGFR dip protocol for ACEi/ARB and SGLT2i:

• Expected initial eGFR decline of 10-30% is hemodynamic and renoprotective; do NOT discontinue
• Recheck BMP in 2-4 weeks after initiation or dose change
• Discontinue if: eGFR drop >30% from baseline, potassium >5.5 (despite dietary modification), or symptomatic hypotension

Step 3: CKD Complications Management

Step 4: Medication Dose Adjustments

Step 5: Monitoring Schedule and Nephrology Referral

Monitoring frequency by KDIGO risk category:

Nephrology referral criteria (refer when ANY of the following):

• eGFR <30 mL/min/1.73m² (G4-G5)
• Rapid eGFR decline (>5 mL/min/year sustained)
• UACR >300 mg/g (A3 / nephrotic-range proteinuria)
• Persistent hematuria with proteinuria (glomerulonephritis evaluation)
• Refractory hypertension despite ≥4 agents
• Persistent hyperkalemia (>5.5) limiting RAAS blockade
• Unexplained anemia with eGFR <45
• CKD of unknown etiology
• Hereditary kidney disease (PKD, Alport syndrome)
• Recurrent nephrolithiasis with CKD progression
• eGFR <20: discuss dialysis modality and AV access planning

Checkpoint B: Post-Draft Alignment (Mandatory)

1. Is CKD staged by both GFR category and albuminuria category (e.g., G3a-A2)?
2. Is the patient on an ACEi/ARB if UACR ≥30 or hypertensive?
3. Has an SGLT2 inhibitor been initiated or documented as not indicated?
4. Are all renally-cleared medications dose-adjusted for current eGFR?
5. Has nephrology referral been triggered if criteria met?

Quality Audit

• CKD diagnosis confirmed with ≥2 eGFR or UACR values ≥3 months apart
• CKD staged by both GFR category (G1-G5) and albuminuria category (A1-A3)
• CKD-EPI 2021 race-neutral equation used for eGFR calculation
• eGFR trajectory plotted (at least 3 values over 12 months) to assess rate of decline
• UACR checked at least annually (more frequently if A2-A3)
• ACEi or ARB prescribed and titrated to max tolerated dose if UACR ≥30 or HTN
• SGLT2 inhibitor prescribed if eGFR ≥20 and UACR ≥200 (or other KDIGO indications)
• Finerenone considered for T2DM + CKD with persistent albuminuria on max ACEi/ARB
• Potassium and creatinine checked within 2-4 weeks of RAAS/SGLT2i initiation or dose change
• Nephrotoxic medications identified and discontinued or dose-adjusted (NSAIDs, aminoglycosides)
• CKD complications screened: anemia, acidosis, hyperkalemia, CKD-MBD
• Nephrology referral placed if eGFR <30, rapid decline, or refractory complications
• Vaccination status reviewed (Hepatitis B series if not immune; influenza, pneumococcal)
• Patient educated on CKD stage, prognosis, and self-management (sodium restriction, medication safety)

Guidelines

• Never use race-based eGFR equations; the CKD-EPI 2021 race-neutral equation is the current standard per NKF/ASN joint statement
• ACEi and ARB should NOT be combined (dual RAAS blockade increases hyperkalemia and AKI without additional benefit per ONTARGET/VA NEPHRON-D)
• An initial eGFR dip of up to 30% after starting ACEi/ARB or SGLT2i is expected and hemodynamically mediated; this is NOT a reason to discontinue unless the decline is greater than 30% or accompanied by hyperkalemia
• SGLT2 inhibitors can be initiated at eGFR ≥20 mL/min/1.73m² and continued until dialysis per DAPA-CKD and EMPA-KIDNEY data; do NOT withhold based on older eGFR cutoffs
• NSAIDs are CONTRAINDICATED in CKD regardless of stage due to hemodynamic effects on GFR and direct nephrotoxicity; this includes OTC ibuprofen and naproxen
• Metformin is safe at eGFR ≥30 but should be reduced to 1000mg/day if eGFR 30-45 and discontinued below 30; the 2016 FDA safety update relaxed the prior eGFR <60 restriction
• Patients with CKD G4-G5 should have AV fistula discussion and nephrology co-management for dialysis planning ≥12 months before anticipated dialysis start
• Every CKD patient should be offered the complete Hepatitis B vaccine series if not already immune (anti-HBs titer); CKD patients have impaired vaccine response and may need higher doses