Chronic Kidney Disease in General Practice: Staging, Monitoring & Slowing Progression
From eGFR interpretation to ACEi/ARB prescribing, anaemia management, and referral criteria
CKD affects approximately 10% of the global population and is a major risk factor for cardiovascular disease and end-stage renal failure. This guide covers KDIGO staging, monitoring intervals, ACEi/ARB prescribing, anaemia of CKD, and referral criteria for primary care.
Clinical Decision Support: This article is for educational purposes and supports — not replaces — clinical judgment. Always verify with current national guidelines, BNF, and specialist consultation when needed.
Chronic kidney disease (CKD) affects approximately 10% of the global population and is a major independent risk factor for cardiovascular disease, with patients with CKD stage 3–5 having a 2–4 times higher cardiovascular mortality than the general population. In UK primary care, CKD is predominantly managed by GPs, with nephrology input reserved for advanced or complex cases.
KDIGO CKD Staging: eGFR and Albuminuria
CKD is defined as abnormalities of kidney structure or function, present for >3 months, with implications for health. Staging uses both eGFR (G stages) and albuminuria (A stages) — the combination determines prognosis and monitoring frequency.
| G Stage | eGFR (mL/min/1.73m²) | Description |
|---|---|---|
| G1 | ≥90 | Normal or high (with kidney damage markers) |
| 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 |
| A Stage | ACR (mg/mmol) | Description |
|---|---|---|
| A1 | <3 | Normal to mildly increased |
| A2 | 3–30 | Moderately increased (microalbuminuria) |
| A3 | >30 | Severely increased (macroalbuminuria) |
A single low eGFR does not diagnose CKD — it must be confirmed on a repeat test at least 90 days later. Acute causes (dehydration, AKI, recent contrast) must be excluded before labelling as CKD.
Monitoring Intervals in CKD
| CKD Stage | Monitoring Frequency | Tests |
|---|---|---|
| G1–G2, A1 | Annual | eGFR, ACR, BP, electrolytes |
| G3a, A1–A2 | Every 6–12 months | eGFR, ACR, BP, electrolytes, Hb, calcium, phosphate |
| G3b–G4 | Every 3–6 months | Above + PTH, bicarbonate, uric acid |
| G5 (pre-dialysis) | Every 1–3 months | Full CKD panel; nephrology co-management |
Slowing CKD Progression: Key Interventions
Blood Pressure Control
Hypertension is both a cause and consequence of CKD. Target BP in CKD is <140/90 mmHg (or <130/80 mmHg if ACR ≥70 mg/mmol). ACE inhibitors or ARBs are the preferred antihypertensives in CKD with proteinuria — they reduce intraglomerular pressure and slow progression independently of BP lowering.
SGLT2 Inhibitors in CKD
Dapagliflozin (Forxiga) is now licensed for CKD (eGFR 25–75 mL/min/1.73m²) regardless of diabetes status, following the DAPA-CKD trial. It reduces the risk of sustained eGFR decline, end-stage kidney disease, and cardiovascular death by approximately 39%. This is a major advance in CKD management in primary care.
Anaemia of CKD
- Suspect CKD anaemia if Hb <130 g/L (men) or <120 g/L (women) with eGFR <60
- Exclude other causes first: iron deficiency (ferritin, transferrin saturation), B12/folate deficiency, haemolysis
- Iron deficiency is common in CKD — treat with oral iron first; IV iron if oral not tolerated or ineffective
- Erythropoiesis-stimulating agents (ESAs): Refer to nephrology if Hb <100 g/L despite iron repletion
- Target Hb with ESA: 100–120 g/L (avoid >130 g/L — increased cardiovascular risk)
Referral Criteria to Nephrology
- eGFR <30 mL/min/1.73m² (G4–G5)
- ACR >70 mg/mmol (A3)
- Rapidly declining eGFR (>5 mL/min/1.73m² per year or >10 mL/min/1.73m² in 5 years)
- Haematuria with proteinuria (possible glomerulonephritis)
- Refractory hypertension despite 3+ antihypertensives
- Suspected renal artery stenosis
- Metabolic complications: refractory hyperkalaemia, acidosis, hyperphosphataemia
Key Clinical Takeaways
- CKD requires two eGFR readings >90 days apart — do not diagnose on a single result
- Stage using both eGFR (G1–G5) and albuminuria (A1–A3) — combination determines prognosis
- ACEi/ARB are preferred antihypertensives in CKD with proteinuria — monitor eGFR and K+ closely
- Dapagliflozin is now licensed for CKD regardless of diabetes — significant renoprotective benefit
- Refer to nephrology if eGFR <30, ACR >70, or rapidly declining eGFR
- Annual monitoring minimum for all CKD patients; more frequent for advanced stages