Chronic kidney disease

Chronic kidney disease is the reduction in kidney function and/or kidney damage which has existed for over 3 months and is associated with other health-related issues (National Institute for Health and Care Excellence (NICE), 2023). Chronic kidney disease is progressive and incurable condition, usually found in adults and carries a high burden of morbidity and mortality (Thomas, 2019).

The signs and symptoms of chronic kidney disease vary according to the disease as well as its severity, although many people are asymptomatic until their disease becomes advanced (Webster et al, 2016). An individual is not diagnosed with chronic kidney disease unless they have a decreased estimated glomerular filtration rate (eGFR) and/or raised albumin creatinine ratio (ACR). Other signs and symptoms of chronic kidney disease include:

• anaemia
• decreased appetite
• electrolyte disturbance
• fatigue
• pruritis
• hypertension
• nausea
• oedema
• shortness of breath

There are several causes of chronic kidney disease, the most common being related to diabetes and hypertension in developed countries (Singh and Krause, 2023). NICE (2023) list the following causes of chronic kidney disease:

• intrinsic kidney damage secondary to:
  • diabetes, such as diabetic nephropathy
  • glomerular disease, such as glomerulonephritis
  • hypertension, such as hypertensive nephropathy
• history of acute kidney injury
• nephrotoxic medications
  • aminoglycosides
  • angiotensin-converting enzyme inhibitors 
  • nonsteroidal anti-inflammatory drugs 
• obstructive uropathies
  • prostatic disease
  • structural abnormalities
  • urinary tract calculi (stones)
• systemic disease
  • myeloma
  • systemic lupus erythematosus
  • vasculitis
• familial or hereditary disease
  • Alport's syndrome
  • autosomal dominant polycystic kidney disease
• cardiovascular disease, such as renal artery stenosis

Some individuals may have multiple comorbidities of chronic kidney disease.

As well as the specific cause(s) of chronic kidney disease, which in some individuals will be a diagnosis of exclusion or may never be known, the severity of the disease is classified using the estimated glomerular filtration rate and albumin creatinine ratio. Specific diagnoses are made based on:

• individual clinical history, such as diabetes, obstructive uropathy
• family history of renal diseases, such as autosomal dominant polycystic kidney disease
• the clinical presentation, such as signs and symptoms of diseases associated with chronic kidney disease, such as systemic lupus erythematosus
• blood tests for specific diseases, for example myeloma
• imaging, such as ultrasound (eg kidney stones)
• kidney biopsy for specific diseases (eg Goodpasture’s syndrome)
• urine tests, such as albumin creatinine ratio

A diagnosis must exclude acute kidney injury, because this is potentially reversible while chronic kidney disease is not.

The severity of chronic kidney disease is staged according to the level of increase

Since chronic kidney disease is progressive, the aim of management is to slow its progression and manage its signs, symptoms and sequalae. As always, patient-centred care is the priority, with a focus on individual preferences and management according to need (NICE, 2021).  

A patient with advanced (ie an estimated glomerular filtration rate <30) (G4), or rapidly progressing disease (ie a decrease of more than 25% in estimated glomerular filtration rate in a year), should always be referred to the kidney care team for management (NICE, 2023).

1. Management of chronic kidney disease relies on establishing an aetiology and diagnosis, as described above. Understanding aetiology and a diagnosis allows for disease-specific treatments. Disease classification and progression monitoring are important in predicting treatment strategies, such as the timing for renal replacement therapy.
2. First-line management of chronic kidney disease focuses on controlling individual diseases, for example blood glucose control in diabetes (glycated haemoglobin

Cheung AK, Chang TI, Cushman WC et al. Executive summary of the KDIGO 2021 Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease. K Int. 2021;99(3):559-569. https://doi.org/10.1016/j.kint.2020.10.026 

Eaglestone G, Ellis P. Cystatin Cas a marker of renal function in older adults. Nursing Standard. 2009;24(13):35-9. https://doi.org/10.7748/ns2009.12.24.13.35.c7418 

Kidney Disease: Improving Global Outcomes (KDIGO). Clinical practice guideline for the evaluation and management of chronic kidney disease. K Int Suppl. 2013;3(1):1–150

National Institute for Health and Care Excellence (NICE). Chronic kidney disease in adults: assessment and management. 2021. https://www.nice.org.uk/guidance/ng203 (accessed 16 November 2023)

National Institute for Health and Care Excellence. Chronic kidney disease. 2023. https://cks.nice.org.uk/topics/chronic-kidney-disease/ (accessed 16 November 2023)

Palmer SC, Navaneethan SD, Craig JC et al. HMG CoA reductase inhibitors (statins) for people with chronic kidney disease not requiring dialysis. Cochrane Database Syst Rev. 2014;31(5):CD007784. https://doi.org/10.1002/14651858.CD007784.pub2 

Singh M, Krause MW. BMJ Best Practice: Chronic kidney disease. 2023. https://bestpractice.bmj.com/topics/en-gb/84 (accessed