Chronic Kidney Disease Quick Guide

Managing CKD in your primary care practice? Find resources to help you. Follow this handy checklist to ensure you complete your screenings and meet clinical targets, review diagnosis and staging criteria as well as common medications in CKD, gain confidence in managing complications and comorbidities, and know when to refer to a specialist.

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Checklist for CKD Management for Frontline Providers


Clinical Targets

Frequency of Testing/Visits

Next Steps for Uncontrolled/Positive Finding

Estimate GFR and Albuminuria

GFR >=90

Urine ACR <30 mg/g

Stages 1-2: Annually

Stage 3: Semiannual

Stages 4/5: Quarterly

Determine if progressive

Estimate risk for progression (Kidney Failure Risk Equation or KidneyIntelX in diabetics)


Protein Intake

Stage 5: 0.6-0.8 g/kg/d

Sodium intake

Stages 3/4-5: <4g/3 g/d

Stages 3-5 w Htn: <2 g/d

Annually and as needed

Provide dietary counseling (Nutritionist or CDE)

Protein composition recommended: 50% High Biologic Value and 50% plant-based

Blood Pressure Control

Target Blood Pressure: <130/80

Monthly until controlled, then every 3-6 months

Lifestyle modification, Home BP monitoring


ACR <30 mg/g, GFR <60: Use ACE/ARB, CCB, Diuretic

ACR 30-299 mg/g: Use of ACE/ARB suggested ACR >300 mg/d: Use ACE/ARB


ACR<30: Use ACE/ARB, CCB, and/or Diuretic

ACR >30 or GFR<60: Use ACE/ARBR

Diabetes Mellitus Management

HbA1c <7% (range <6.5-8%)

Urine ACR <30 mg/g

Controlled: q 6 mon

Poorly controlled: q 3 mon

Intensify medications to optimize control

With CKD, both metformin and SGLT-2i as first line therapy

Use GLP-1 RA if intolerant to SGLT-2i or GFR <30

Lipid Management

LDL <130 or <100 based on ASCVD risk


Lifestyle modification

Statin therapy for Stage 3-5 (Non-Dialysis)

Metabolic Acidosis

Sodium Bicarbonate >22 meq/l

Stage 1-2: Annual

Stage 3: q 6 mon

Stages 4/5: q 3 mon

If bicarbonate <22 mEq/l, add sodium bicarbonate (650 mg TID) or sodium citrate (30 ml/d


Hgb level >13 mg/dl men, >12 women

Stage 3: Annual

Stages 4-5:q 3 mon

On ESA : q 3 mon

Replete iron orally or IV if iron deficient (FeS04 325 mg TID, Fe gluconate 2-3 mg/kg/d BID-TID)

Erythropoiesis Stimulating Agents if refractory

Bone Metabolic Disease

Normal Calcium and Phopshate concentrations

Screening at GFR <5

Stage 3B: q 6-12mon

Stage 4: q 3-6 mon

Stage 5: q 1-3 mon

Correct hypocalcemia if <7.5 mg/dl (adjust-ed for albumen), symptomatic, or severe hyperPTH

Treat hyperphosphatemia with diet (~900 mg/d) and phosphate binders if >6 mg/dl


Vitamin D

Screening to establish baseline and as needed

Correct as without CKD, if Phosp/calcium normal. Calcitriol or synthetic vitamin D analogs if progressive hyperparathyroidism


Parathyroid hormone level

Stage 3B: Baseline Stage 4: q 6-12 monStage 5: q 3-6 mon

Correct modifiable factors Calcitriol/Vit D analogues for severe progressive disease


Serum Potassium

Stage 1-2: Annual

Stage 3: q 6 mon

Stages 4/5: q 3 mon

Low potassium diet

Reduce or eliminate contributing meds

Correct acidosis

Sodium polystyrene, Patiromer, or Sodium zirconium cyclosilicate

Behavioral Health

Depression Screen: PHQ 2/9

Annual Screening

Confirm diagnosis of depression

Initiate treatment and/or refer



Hepatitis B


1x if GFR <30 or higher risk, repeat in 5y.

Complete Hep B series when GFR <30 and at risk of progression.

Annual influenza vaccination.

Consider administration of PV 13 at 65yrs

Check HepBs Ab to confirm immunity


Diagnosis & Staging

History: majority of cases are asymptomatic and detected incidentally or through screening

     • Chronic kidney disease is defined as any abnormality of kidney function or structure lasting at least 90 days

     • CKD should be distinguished from acute kidney injury (2-7 days) and acute kidney disease (<3 months)

Diagnostic Testing

     • Estimate GFR using serum creatinine, age, gender (typically on lab report, do not adjust by race)

     • Measure urinary albumin excretion: urine albumin to creatine ratio (ACR) preferred test

           • NOTE: In Epic, “Kidney Profile” order includes eGFR, urine albumin, and urine creatinine.

     • Renal ultrasound typically obtained to assess kidney structure and rule out obstruction.

Classification - focus on GFR AND level of albuminuria

     • Stratify GFR into Stages 1-5, urine ACR into stages A1-A3

     • Use table below to classify risk of progression, monitoring frequency, and time interventions

     • Progression defined as drop in GFR category and a 25% decrease from GFR baseline

     • Rapid progression is a decline in GFR of = 5 ml/min/1.73m2 per year

     • If GFR <60, use Kidney Failure Risk Equation to estimate 2 yr and 5 yr of dialysis or renal transplantion ( or KidneyIntelX for diabetic



Diet & Lifestyle


CKD Status



Stage 5 (Possibly Stages 3b-4)

Consider 0.6-0.8 g/kg/d protein (50% high biologic value, 50% plant based) (70 kg pt =70g, ¼ pound of beef or cheese has 28 g protein, ½ cup grain has 3 g)


Stage 3-5

<4 g/d Stage 3, or <;3 g/d for Stage 4-5, symptomatic fluid retention/proteinuria, <2g/d if hypertensive or diabet-ic (1/4 teaspoon salt has 575 g sodium)


Stage 3

<4.7 grams per day (442 mg per banana, 230 mg in ¼ cup orange juice)

Stage 4-5

<3 grams per day


Stage 3-5 (Pre-dialysis)

800-1,000 mg daily (1 calcium carbonate tablet has 500-600 mg elemental Ca)


Stage 3

Restrict to <1.5 liters per day (approximately six 8 oz glasses of water)



30-35 kcal/kg per day



30 minutes a day, five days a week


Delaying Disease Progression


See table

Diabetes Mellitus

See table


  • Annual urine ACR and GFR estimation, start 5 yrs after dx of DM1, upon dx of DM2 

Type 2 DM Treatment Recommendations (see table)

  • Target HbA1c: Range 6.5%-8% depending on comorbidities, life expectancy, CKD severity

  • Use SGLT-2 inhibitor with metformin if GFR >30, and UACR >30 mg/g, particularly if UACR >300 mg/g

  • Use GLP-2 RA if SGLT-2i contraindicated (GFR <30), not tolerated or 3rd antihyperglycemic needed

Managing Complications


Metabolic Acidsosis (See Table)

  • If HC03 <22 mEq/l: treat with oral bicarbonate to normalize level

Hyperkalemia (See Table)

  • Severe (K> 6.0—6.5 mEq/l): clinical emergency mandating immediate care

Iron Deficiency Anemia

  • Iron supplementation useful in both absolute and functional iron deficiency

Bone Mineral Disorder

  • Hypocalcemia: Supplement calcium if severe, progressive secondary hyperparathyroidism, not if mild

  • Vitamin D Deficiency

    • Calcitriol use limited to progressive hyperparathyroidism (PTH levels 2.5-3X upper limit of nml)               

    • Calcitriol 0.25 mg three times a week, if corrected Ca <9.5 and normal phosphate

    • Non-calcium containing binders

    • Other synthetic vitamin D agents

Managing Common Comorbidities


Cardiovascular Disease

Coronary Artery Disease: Antiplatelet Therapy

• Primary Prevention: ASA/other antiplatelet agents may be modestly useful

• Secondary Prevention: Low dose ASA (81 mg) is preferred to higher doses

Heart Failure

• SGLT-2 inhibitors have beneficial effects on HF and CKD, with and without DM

Lipid Disorders

• Treatment recommendations for patients 40-75 years old

• Patients with GFR 15-60 and/or urine ACR >30 mg/g not receiving dialysis or post-transplant with 10 yr ASVCD risk >7.5% should be treated with a statin +/- ezetimbi

• GFR >60 and albuminuria or other kidney disease, should receive a statin or have treatment reserved for those with increased ASCVD risk

• Moderate intensity statin doses recommended (e.g. Atorvastatin 40 mg/d), unless other indications for high dose. Doses of renally excreted statins may need to be reduced.

Clinical Integration Care Delivery Steps


Nephrology Referral Indications

• Clarify cause of CKD and/or assistance managing related complications, AKI or abrupt sustained fall in GFR.

• All Stage 4-5 CKD (GFR <30), urine ACR >300 mg/g, KidneyIntelXTM medium or high risk score

• Resistent hypertension, persistent hyper-/hypokalemia, hyperphosphatemia, anemia warranting ESA

• Planning for or initiation of dialysis (if risk of kidney failure within next year is >10-20%) • Transplantation: Should be considered if GFR <20 with likely progressive, irreversible CKD over next 6-12 months

Find a nephrologist


Care Management Referral Indications

• Multiple no-shows, treatment non-adherence• Demonstrated difficulty managing symptoms and/or disease processes

• Frequent potentially preventable admissions or ED visits

• Complex family dynamics, difficulty accessing needed community-based care, and/or a high “worry score”

Use MSHP Care Management Referral in Epic, email, or call 212-241-7228


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1. Chen TK, Knicely DH, Grams ME, Chronic Kidney Disease Diagnosis and Man-agement: A Review. JAMA. 2019 October 01; 322(13): 1294–1304

2. KDIGO 2020 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease Kidney International Supplements 2020;98:1-120

3. KDIGO 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease–Mineral and Bone Disorder (CKD-MBD) Kidney International Supplements, 2017;7:1-