ambossIconambossIcon

Chronic kidney disease

Last updated: June 25, 2025

Quick guidetoggle arrow icon

Related quick guide: Acute kidney injury

Diagnostic approach

Diagnostic criteria

Management checklist

Red flag features

Icon of a lock

Register or log in , in order to read the full article.

Summarytoggle arrow icon

Chronic kidney disease (CKD) is defined as an abnormality of kidney structure or function that persists for > 3 months and affects health. The most common causes of CKD in the United States are diabetes mellitus, hypertension, and glomerulonephritis. Most patients remain asymptomatic until their kidney function is severely impaired due to the organ's efficient compensatory mechanisms and significant renal reserve. Patients are most commonly diagnosed via routine screening (e.g., screening of high-risk populations, routine blood tests that include serum creatinine to estimate glomerular filtration rate). At advanced disease stages, patients may present with symptoms of fluid overload (e.g., peripheral edema) and/or uremia (e.g., fatigue, pruritus). Patients with CKD have a significantly increased risk of developing atherosclerotic cardiovascular disease (ASCVD). Laboratory studies may show metabolic complications, such as hyperkalemia, hyperphosphatemia, hypocalcemia, and metabolic acidosis. Management is aimed at slowing CKD progression and preventing and/or managing complications. This includes treating the underlying disease, avoiding nephrotoxic substances, maintaining adequate hydration and nutrition, pharmacotherapy (e.g., RAAS inhibitors, SGLT2 inhibitors, and statins), and addressing complications such as anemia of CKD and CKD-mineral and bone disorder (CKD-MBD). Renal replacement therapy (i.e., dialysis or renal transplantation) is required if CKD progresses to end-stage renal disease (ESRD).

See also “Acute kidney injury” (AKI) and “Diabetic kidney disease” (DKD).

Icon of a lock

Register or log in , in order to read the full article.

Epidemiologytoggle arrow icon

  • Prevalence [1]
    • An estimated 37 million individuals (15%) in the US have CKD.
    • 726,000 individuals have ESRD.
  • Incidence: > 350 cases of ESRD per million individuals annually [1]

Epidemiological data refers to the US, unless otherwise specified.

Icon of a lock

Register or log in , in order to read the full article.

Etiologytoggle arrow icon

Icon of a lock

Register or log in , in order to read the full article.

Pathophysiologytoggle arrow icon

Pathophysiology depends on the underlying condition, any of which will eventually lead to progressive nephron loss, structural damage, and impaired kidney function.

Underlying conditions

Diabetic nephropathy [4]

Hypertensive nephropathy

Glomerulonephritis (GN)

Consequences

Reduced GFR

Reduced endocrine activity

Reduced gluconeogenesis

Icon of a lock

Register or log in , in order to read the full article.

Clinical featurestoggle arrow icon

Patients are often asymptomatic until later stages due to the exceptional compensatory mechanisms of the kidneys.

Manifestations of Na+/H2O retention

Manifestations of uremia

Kidney OUTAGES: hyperKalemia, renal Osteodystrophy, Uremia, Triglyceridemia, Acidosis (metabolic), Growth delay, Erythropoietin deficiency (anemia), Sodium/water retention (consequences of chronic kidney disease)

Icon of a lock

Register or log in , in order to read the full article.

Classificationtoggle arrow icon

General principles [2][8]

CKD is classified according to cause, eGFR category, and albuminuria category (CGA classification).

Cause [8]

  1. Systemic vs. primary cause: Determine if the cause of CKD is systemic (e.g., diabetes) or primary (e.g., polycystic kidney disease).
  2. Type: Determine the type (presumed or confirmed) of the damage within the kidney.
    • Glomerular
    • Tubulointerstitial
    • Vascular
    • Cystic and congenital

eGFR and albuminuria [8]

Risk of progression and complications of CKD based on eGFR and albuminuria category [8]
eGFR category (mL/min/1.73 m2) Persistent albuminuria category (UACR)

A1: < 30 mg/g or < 3 mg/mmol

(normal to mildly increased albuminuria)

A2: 30–300 mg/g or 3–30 mg/mmol

(moderately increased albuminuria)

A3: > 300 mg/g or > 30 mg/mmol

(severely increased albuminuria)

Stage G1 CKD: ≥ 90 (normal or high) Low risk* Moderate risk High risk
Stage G2 CKD: 60–89 (mildly low)
Stage G3 CKD G3a: 45–59 (mildly to moderately low) Moderate risk High risk Very high risk
G3b: 30–44 (moderately to severely low) High risk Very high risk
Stage G4 CKD: 15–29 (severely low) Very high risk
Stage G5 CKD: < 15 (kidney failure)

*Stages G1A1 and G2A1 only indicate CKD if there are other markers of kidney damage.

End-stage renal disease (ESRD) [10]

Icon of a lock

Register or log in , in order to read the full article.

Screeningtoggle arrow icon

Indications for screening [8]

Consider screening patients with risk factors for CKD, e.g.: [1][8]

Screening methods [8]

Icon of a lock

Register or log in , in order to read the full article.

Diagnosistoggle arrow icon

Approach [8]

A single abnormal GFR or UACR level is not diagnostic for CKD.

Confirm CKD with repeat testing if albuminuria, hematuria, or low GFR are detected incidentally.

Assessment of GFR [8]

Use a validated equation tested within the relevant geographical region. Avoid incorporating race into assessment of GFR.

Estimated GFR (eGFR)

  • Serum creatinine-based eGFR formulas (eGFRcr): preferred initial test for most patients
  • Creatinine and cystatin C-based eGFR (eGFRcr-cys) is preferred when:
    • There is diagnostic uncertainty
    • eGFRcr may be inaccurate
    • CKD staging is required
  • Cystatin C-based eGFR (eGFRcys): less accurate than eGFRcr-cys
  • Measured urine creatinine clearance: Consider when eGFRcr-cys may be inaccurate and mGFR is unavailable.

When eGFRcr and eGFRcys align, all three estimates (i.e., eGFRcr, eGFRcys, and eGFRcr-cys) have a similar degree of accuracy. When eGFRcr and eGFRcys differ, eGFRcr-cys is more accurate than eGFRcr or eGFRcys. [8]

Measured GFR (mGFR)

  • Gold-standard test but not routinely indicated
  • May be considered in selected cases when a more accurate assessment would alter management.

Diagnostic criteria [8]

Criteria for CKD

Suspect AKI (with or without underlying CKD) in patients with a rapid rise in creatinine level (i.e., over days rather than weeks to months).

A diagnosis of CKD requires a persistent eGFR < 60 mL/min/1.73 m2 and/or markers of kidney damage lasting more than 3 months.

CKD progression

Validated risk-stratification tools can be used to identify patients at increased risk for kidney failure to help guide appropriate referrals to specialist nephrology care.

Icon of a lock

Register or log in , in order to read the full article.

Initial studiestoggle arrow icon

Laboratory studies [8]

Blood tests

Urine studies

Suspect plasma cell dyscrasia if the UPCR is significantly higher than the UACR. Send a urine sample for protein electrophoresis to identify urine proteins other than albumin (e.g., Bence Jones protein).

Ultrasound of the kidneys and urinary tract [8]

Consider obtaining an ultrasound of the kidneys and urinary tract as part of the routine evaluation of all patients with CKD.

Icon of a lock

Register or log in , in order to read the full article.

Additional studiestoggle arrow icon

Additional studies should be considered based on clinical suspicion or if an underlying cause of CKD is not apparent following an initial assessment. [8]

Integration of information from the patient's clinical presentation, laboratory tests, imaging, and in some cases, renal biopsy is needed to determine the underlying cause.

Noninvasive testing [8]

Investigations for specific underlying causes of CKD
Examples Suggestive features Common additional studies
Diabetes
Glomerulonephritis
Multiple myeloma
Renal artery stenosis
Amyloidosis

Renal biopsy [8]

  • Often not required to establish the cause
  • Consider in either of the following situations:
    • Rapid and unexplained decline in eGFR
    • Need for diagnostic confirmation of the underlying cause (e.g., glomerulonephritis) prior to starting disease-specific therapy

Discuss the risks and benefits of biopsy with the patient and use shared decision-making.

Icon of a lock

Register or log in , in order to read the full article.

Managementtoggle arrow icon

The following guidance applies to patients with CKD stage G1–G5 who are not on dialysis and have not had renal transplantation.

Approach [8]

The goals of management are to delay the progression of CKD and prevent and/or manage complications.

If CKD progression or complications are detected during follow-up, review the current management and assess for reversible causes of progression (e.g., nephrotoxin exposure, medications affecting glomerular perfusion, urinary tract obstruction).

Prevention of AKI in patients with CKD is vital to prevent disease progression.

If there are indications for acute dialysis, urgently start renal replacement therapy.

ASCVD risk assessment [8]

Management of ASCVD reduces cardiovascular morbidity and mortality and helps prevent CKD progression.

Cardiovascular disease (e.g., coronary artery disease, stroke) is the leading cause of death in patients with CKD. The risk of cardiovascular events is higher in patients with more advanced stages of CKD. [3]

Lifestyle changes

  • Encourage a healthy lifestyle, including:
  • For any recommendations, consider the patient's age, ethnicity, comorbidities, and access to resources.
  • Reassess lifestyle factors every 3–6 months.

Nutrition [8]

Dietary protein restriction must only be prescribed under close clinical supervision and in consultation with a nutritionist.

Obtain a nutritionist consult for all patients with CKD.

Medication management [8][17]

Weigh the risks and benefits of potentially nephrotoxic substances on an individual basis.

In acutely ill patients with CKD, consider temporarily holding renally cleared medications and medications that can detrimentally affect glomerular perfusion (e.g., NSAIDs, ACE inhibitors, ARBs) to reduce the risk for AKI.

Vaccinations

Patients with CKD are at an increased risk for infection.

Patients with CKD may be immunocompromised. Consider the patient's current immune status and consult a specialist before administering live vaccines. [3]

Nephrology consultation [8]

Indications for nephrology consultation include any of the following:

Renal replacement therapy [8]

Plan for pre-emptive renal transplantation and/or dialysis access in adults if the eGFR falls to < 15–20 ml/min per 1.73 m2 or if the KFRE 2-year risk is > 40%. [8]

Icon of a lock

Register or log in , in order to read the full article.

Pharmacotherapytoggle arrow icon

Antihypertensives [8][19]

Avoid any combination of ACE inhibitors, ARBs, and/or direct renin inhibitors due to the increased risk for hyperkalemia and AKI.

Blood pressure control is essential to prevent ASCVD complications, reduce mortality, and help delay disease progression in patients with CKD.

Lipid lowering therapy [8][20][21]

For patients with an eGFR < 60 mL/min/1.73 m2 (eGFR category G3–G5), adjust the statin dose to reduce the risk for toxicity.

Individuals with CKD often have dyslipidemia (e.g., triglycerides, LDL, HDL) due to alterations in lipoprotein metabolism.

Diabetes medications [8][22]

  • SGLT2 inhibitors [8]
    • Recommended for patients with or without diabetes who have:
    • Once started, continue even if eGFR declines to < 20 mL/min/1.73 m2.
    • Stop therapy if it cannot be tolerated or if starting RRT.
    • Withhold therapy during surgery, prolonged fasting, or critical medical illness.
  • GLP-1 receptor agonists: indicated in patients with T2DM and CKD who have not met glycemic targets despite metformin and SGLT2 inhibitor use or who cannot use those medications
  • General considerations
    • HbA1c may not accurately reflect glycemic control in patients with CKD and an eGFR < 30 mL/min/1.73 m2; confirm with results from ambulatory glucose monitoring.
    • Medications may need to be reduced or stopped as eGFR declines.
    • See “Diabetic kidney disease” for further information on managing diabetes in patients with CKD.

SGLT-2 inhibitors and GLP-1 receptor agonists can slow CKD progression and reduce urinary albumin excretion and ASCVD events. [22][23]

Discontinue metformin in patients who develop CKD stage G4–G5; continue SGLT-2 inhibitors if tolerated.

Uric acid-lowering therapy [8]

Low-dose colchicine or glucocorticoids (intra-articular or oral) are preferred over NSAIDs to treat acute gout in patients with CKD.

Antiplatelet therapy [8]

Icon of a lock

Register or log in , in order to read the full article.

Monitoring for complicationstoggle arrow icon

  • Screening tests for complications are indicated in all patients with CKD at diagnosis to establish a baseline.
  • Patients with CKD categories G3–G5 require repeat testing at regular intervals.

In CKD, close surveillance of serum potassium, calcium, and phosphate levels is essential.

Overview of screening for CKD complications [8]
Screening test

Screening frequency

(CKD category G3–G5)

Potential findings Management
CBC
  • Every 6–12 months
Potassium [17]
  • Repeat as needed.
Mineral and bone disorder panel [24] PTH
  • Every 3–12 months
  • See “Management” in “CKD-MBD.”
Phosphate and total calcium
  • Every 1–12 months
Vitamin D
  • Calcidiol: Repeat as needed.
  • Calcitriol: No specific indication or monitoring frequency exists.
Coagulation screen
Blood gases
  • Repeat as needed.

Screening and periodic monitoring for complications are indicated in all patients with CKD and eGFR < 60 mL/min/1.73 m2.

Icon of a lock

Register or log in , in order to read the full article.

Dot phrasetoggle arrow icon

We appreciate your feedback!
We’re testing dot phrases with ready-to-use assessment and plan templates.
Please verify all information before use; follow local protocols and procedures when available.

Chronic kidney disease (outpatient management)

Assessment: This is a @AGE@-year-old @SEX@ with CKD, stage [***] (eGFR *** mL/min/1.73 m2), likely secondary to [***hypertension/diabetes]. [***Unstable/Stable] renal function over the past year. [***No] current signs of uremia or acute decompensation. Recent labs show [K+ *** mmol/L] and ACR [***]. Blood pressure [***is/is not] at target of [***/*** mm Hg]. [***No] evidence of mineral and bone disorder or anemia.

Plan:

BMP in 3 months to monitor renal function and electrolytes; last value: [***]

–Urine ACR annually; last value: [***]

CBC annually; last hemoglobin [***]; consider ESAs for Hb ≤ 9–10 g/dL in anemia of CKD

PTH annually; last value [***]

–Continue/Increase/Decrease [ACE/ARB *** mg ***frequency] for blood pressure and renal protection.

–Start/Continue [***statin *** mg once daily] for ASCVD risk reduction.

–Avoid NSAIDs and nephrotoxic agents.

–Low-sodium and low-potassium diet

–Educate on CKD progression and signs of worsening (e.g., fatigue, swelling, reduced urine output).

–Discuss importance of medication adherence, adequate fluid intake, and dietary modifications.

–Follow up in 3 months to review labs and reassess kidney function.

–Refer to nephrology if CKD progresses.

Icon of a lock

Register or log in , in order to read the full article.

Complicationstoggle arrow icon

For recommendations on screening tests and frequencies, see “Monitoring for complications.” Specialist consultation (e.g., with a nephrologist) is advised for the management of complications.

Common acute complications [26]

Maintain a low threshold for suspecting infections and initiating empiric antibiotics, as signs of sepsis may be vague or absent in patients with CKD. [26][29]

Calciphylaxis [30][31]

Anemia of chronic kidney disease [3][32][33]

Management

Treatment with ESAs is not recommended for patients with Hb levels ≥ 10 g/dL because their use has been associated with increased mortality, stroke, and venous thromboembolism.

Chronic kidney disease-mineral and bone disorder (CKD-MBD) [34][35]

Hyperphosphatemia, hypocalcemia, and insufficient production of vitamin D in patients with CKD may lead to secondary hyperparathyroidism and consequent renal osteodystrophy.

Growth delay and developmental delay in children

We list the most important complications. The selection is not exhaustive.

Icon of a lock

Register or log in , in order to read the full article.

Special patient groupstoggle arrow icon

Chronic kidney disease in pregnancy [36]

Icon of a lock

Register or log in , in order to read the full article.

Related One-Minute Telegramtoggle arrow icon

Interested in the newest medical research, distilled down to just one minute? Sign up for the One-Minute Telegram in “Tips and links” below.

Icon of a lock

Register or log in , in order to read the full article.

Start your trial, and get 5 days of unlimited access to over 1,100 medical articles and 5,000 USMLE and NBME exam-style questions.
disclaimer Evidence-based content, created and peer-reviewed by physicians. Read the disclaimer