Chronic Kidney Disease and Progression
Core concepts
CKD is defined by ≥3 months of decreased GFR (<60) or markers of kidney damage (albuminuria, hematuria, structural abnormality). Stage by GFR category (G1–G5) and albuminuria category (A1–A3). Complications to know: anemia (erythropoietin deficiency, iron deficiency), CKD-mineral bone disorder (high PTH, high phosphate, low calcitriol), metabolic acidosis, hyperkalemia, and volume overload.
Progression is slowed by blood pressure control, ACE inhibitors/ARBs for albuminuria, SGLT2 inhibitors, finerenone, dietary sodium and protein restriction, and avoiding nephrotoxins. Uremia with pericarditis, encephalopathy, or refractory volume/electrolyte problems prompts dialysis.
Traps
Do not start an ACE inhibitor without checking potassium and creatinine; a small creatinine rise is acceptable. Anemia in CKD is normocytic; if microcytic, look for iron deficiency or other causes. Phosphate binders and active vitamin D are used for CKD-MBD but over-suppression of PTH causes adynamic bone disease. Beware drug dosing-renally cleared drugs need adjustment.
Rule of thumb
For every CKD patient, address BP, albuminuria, SGLT2 inhibitor, sodium intake, and avoid NSAIDs/contrast when possible.
Worked example
A 60-year-old with CKD G3b/A3 and diabetes has BP 150/90. Start an ACE inhibitor or ARB plus an SGLT2 inhibitor, target BP <130/80, monitor potassium and creatinine, and counsel on nephrotoxin avoidance.