Chronic Kidney Disease (CKD) 🫘
On-call CKD aid based on KDIGO 2024: definition, CGA staging heat map (GFR × albuminuria chips), RASi/SGLT2i, sick-day holds, and when to refer.
KDIGO CKD heat map
Tap chips or a cell on the chart
GFR category (eGFR, ml/min/1.73 m²)
Albuminuria category (ACR)
Prefer urine ACR in mg/mmol (SI). Approximate mg/g shown for reference.
Prognosis chart — your cell is outlined
GFR (ml/min/1.73 m²)
A1
Normal to mildly increased
<3 mg/mmol
A2
Moderately increased
3–30 mg/mmol
A3
Severely increased
>30 mg/mmol
G1 ≥90
Normal or high
G2 60–89
Mildly decreased
G3a 45–59
Mildly to moderately decreased
G3b 30–44
Moderately to severely decreased
G4 15–29
Severely decreased
G5 <15
Kidney failure
LowModerateHighVery high
Green = low risk (no CKD if no other markers of kidney damage). Tap a cell or use chips above.
Select GFR and albuminuria (chips or chart) to classify.
🧠 Definition (based on KDIGO 2024)
- CKD = abnormalities of kidney structure or function for ≥3 months, with implications for health.
- Classify by Cause, GFR category (G1–G5), and Albuminuria category (A1–A3) — abbreviated CGA. Use the heat map above.
- Markers of kidney damage include ACR ≥3 mg/mmol (≥30 mg/g), urine sediment abnormalities, persistent haematuria, imaging/histology abnormalities, tubular disorders, or kidney transplant — even if eGFR ≥60.
- G1 or G2 with A1 is not CKD unless other markers of kidney damage are present.
- Do not assume chronicity from a single abnormal eGFR or ACR; confirm ≥3 months (or prior results / imaging / transplant history). Treat urgently while awaiting confirmation if clinically indicated.
📞 On-call
- Is this AKI on CKD, progressive CKD, or a stable baseline? Compare with prior creatinines.
- Check K⁺, bicarbonate, fluid status, urine output, and obstruction (bladder scan / USS if indicated).
- Review nephrotoxins and “sick day” meds if dehydrating illness: SADMANS — Sulfonylureas, ACEi, Diuretics/DRI, Metformin, ARBs, NSAIDs, SGLT2i. Document a clear restart plan (based on KDIGO Practice Point 4.3.2).
- Hyperkalaemia, pulmonary oedema, severe acidosis, or uraemic emergency → treat and escalate (see related topics).
⚠️ Escalate
- AKI on CKD, K⁺ emergency, fluid overload with respiratory compromise, severe metabolic acidosis, suspected obstruction, or need for urgent dialysis.
- New nephrotic-range proteinuria, active urinary sediment, or systemic features of glomerulonephritis.
💊 Delay progression (based on KDIGO)
- RASi (ACEi or ARB): start for severely increased albuminuria (A3) without diabetes (1B); for A2–A3 with diabetes (1B); suggest for A2 without diabetes (2C). Use highest tolerated approved dose. Avoid combining ACEi + ARB + DRI (1B).
- Check BP, creatinine, and K⁺ within 2–4 weeks of starting or uptitrating RASi. Continue unless creatinine rises >30% within 4 weeks. Continue even if eGFR falls below 30 unless symptomatic hypotension, refractory hyperkalaemia, or eGFR <15 with uraemic symptoms needing dose reduction/stop.
- SGLT2i (1A): T2D + CKD with eGFR ≥20; also adults with CKD and eGFR ≥20 plus ACR ≥20 mg/mmol, or heart failure (any ACR). Suggest for eGFR 20–45 with ACR <20 mg/mmol (2B). Continue if eGFR later falls below 20 unless not tolerated or KRT started; expected early eGFR dip is usually not a reason to stop.
- Withhold SGLT2i during prolonged fasting, surgery, or critical illness (ketosis risk).
- BP: align with KDIGO BP guidance (typically SBP target <120 mmHg if tolerated in adults); individualise if frailty, postural hypotension, or limited life expectancy.
- Sodium <2 g/day (<5 g salt/day) if appropriate; avoid high protein intake (>1.3 g/kg/day) in adults at risk of progression.
📈 Monitoring & referral
- Assess ACR and GFR at least annually; more often at higher heat-map risk (see tool: suggested times/year). Change in eGFR >20% (or >30% after starting haemodynamically active drugs) warrants evaluation. Doubling of ACR exceeds expected variability.
- In CKD G3–G5 use a validated kidney-failure risk equation when available. ~3–5% 5-year risk can guide nephrology referral alongside eGFR/ACR.
- Refer / involve nephrology (Fig. 48): eGFR <30; uncertain cause; hereditary kidney disease; ACR ≥30 mg/mmol with haematuria, or ACR >70 mg/mmol; sustained rapid decline; refractory HTN (≥4 agents); persistent K⁺/acidosis/anaemia/CKD-MBD issues; recurrent extensive stones; or high predicted KRT risk.
Related NICE guidance
NICENICE NG203 — Chronic kidney disease: assessment and management
Full guidance on nice.org.uk. BetterCall is not endorsed by NICE.
Note Template
Ready-to-use clinical note structure
🕒 15 / 10 / 2026 — 02:12 ATRP re: CKD / renal function Patient: [age] [sex] Admission Dx: [reason for admission] PMHx: [diabetes / HTN / known CKD / other] Baseline creatinine / eGFR: [ ] (date) 🧾 Hx: • Context: [incidental eGFR / rising creatinine / electrolyte issue / fluid overload] • Symptoms: [oliguria, oedema, uraemic symptoms, haematuria] • Nephrotoxins / sick-day meds: [ACEi/ARB, diuretic, NSAID, SGLT2i, metformin, other] • Urine output / fluid balance: [ ] 🩺 Exam: • HR: __ BP: __ Temp: __ RR: __ SpO₂: __ • Fluid status: [euvolaemic / dry / overloaded] • Bladder: [ ] 📋 Labs / staging (KDIGO CGA): • Current creatinine / eGFR: [ ] → G category: [G1–G5] • Urine ACR: [ ] mg/mmol → A category: [A1–A3] • K⁺ / HCO₃⁻ / Hb: [ ] 📋 Impression: CKD [G_A_] · [stable / AKI on CKD / progressive] · Cause: [ ] 📌 Plan: • Hold/adjust: [ ] • Repeat U&E / ACR timing: [ ] • Imaging if needed: [ ] • Escalate / renal consult: [yes/no, advice] • Restart plan for held meds: [ ] 👤 [Your Name], [Role] IMC: _______
Educational reference only. Medical disclaimer