What is the appropriate work‑up and management for a typical adult (>45 years) with risk factors such as hypertension, diabetes, or cardiovascular disease who may have chronic kidney disease?

Work-Up and Management of Chronic Kidney Disease in Adults with Risk Factors

Screen immediately with both estimated GFR (eGFR) and spot urine albumin-to-creatinine ratio (UACR) in all adults over 45 with hypertension, diabetes, or cardiovascular disease, as CKD can be diagnosed by either abnormality and requires both tests for complete risk stratification. 1, 2

Initial Diagnostic Work-Up

Confirm CKD Diagnosis

• Measure both eGFR and UACR on all at-risk patients, as these provide independent prognostic information for cardiovascular events, CKD progression, and mortality 1, 2
• Use the CKD-EPI 2021 equation to calculate eGFR from serum creatinine, age, and sex 1
• Obtain UACR on a random spot urine sample (not dipstick), and confirm any result ≥30 mg/g with an early morning sample 1, 2
• CKD is defined as eGFR <60 mL/min/1.73 m² OR UACR ≥30 mg/g persisting for at least 3 months 1, 2

Establish Chronicity and Etiology

• Review historical creatinine values to confirm kidney dysfunction has persisted >3 months, distinguishing CKD from acute kidney injury 1, 2
• If duration unclear, repeat serum creatinine and eGFR within 2-4 weeks 2
• Identify nephrotoxic exposures including NSAIDs, lithium, calcineurin inhibitors, and aminoglycosides 2
• Look for hematuria, pyuria, or casts suggesting glomerulonephritis or other primary kidney diseases 2

Screen for CKD Complications (eGFR <60 mL/min/1.73 m²)

• Complete metabolic panel including sodium, potassium, chloride, bicarbonate to detect metabolic acidosis and hyperkalemia 2, 3
• Complete blood count to screen for anemia 3
• Serum calcium, phosphate, intact PTH, and 25-hydroxyvitamin D to assess for metabolic bone disease 2, 3
• Lipid panel for cardiovascular risk stratification 1, 4

Blood Pressure Management

Target Blood Pressure Based on Albuminuria

• For UACR <30 mg/g: target BP ≤140/90 mmHg 1, 3
• For UACR ≥30 mg/g: target BP ≤130/80 mmHg 1, 3

First-Line Antihypertensive Therapy

• Use ACE inhibitor or ARB for diabetic patients with UACR 30-299 mg/g 1
• Use ACE inhibitor or ARB for all patients (diabetic or non-diabetic) with UACR ≥300 mg/g and/or eGFR <60 mL/min/1.73 m² 1
• Add dihydropyridine calcium channel blockers and/or diuretics if needed to achieve BP targets 3
• Do not discontinue ACE inhibitor/ARB for creatinine increases ≤30% in the absence of volume depletion 1, 2
• Never combine ACE inhibitors with ARBs, as this increases adverse events without additional benefit 1

Monitoring for RAAS Inhibitors

• Check serum creatinine and potassium within 2-4 weeks after initiating ACE inhibitor or ARB 1
• Monitor periodically thereafter for hyperkalemia and changes in kidney function 1

Diabetes Management (if applicable)

Glycemic Control

• Target HbA1c individualized based on comorbidities, but generally <7% for most patients 1
• Adjust doses of oral hypoglycemic agents based on eGFR 5

SGLT2 Inhibitors for Kidney and Cardiovascular Protection

• Use SGLT2 inhibitor in type 2 diabetes patients with eGFR ≥20 mL/min/1.73 m² and UACR ≥200 mg/g to reduce CKD progression and cardiovascular events 1
• SGLT2 inhibitors are recommended for all type 2 diabetes patients with diabetic kidney disease 1

Nonsteroidal Mineralocorticoid Receptor Antagonist

• Use finerenone in type 2 diabetes patients with CKD who are at increased cardiovascular risk or unable to use SGLT2 inhibitor 1
• Monitor potassium at 1 month after initiation, then every 4 months 2
• Finerenone reduces both CKD progression and cardiovascular events 1

Cardiovascular Risk Reduction

Lipid Management

• Initiate statin therapy for all CKD patients over age 50 with eGFR <60 mL/min/1.73 m² 3, 4
• For CKD stage 4 (eGFR 15-29): target LDL-C ≤55 mg/dL with ≥50% reduction from baseline 4
• For CKD stage 3 (eGFR 30-59): target LDL-C ≤70 mg/dL with ≥50% reduction from baseline 4
• Consider adding ezetimibe or PCSK9 inhibitors if LDL targets not achieved with statin alone 3, 4

Antiplatelet Therapy

• Prescribe low-dose aspirin if established cardiovascular disease is present 3

Dietary and Lifestyle Modifications

Protein Restriction

• Limit dietary protein to 0.8 g/kg body weight per day (the recommended daily allowance) for non-dialysis CKD stage 3 or higher 1, 3

Sodium Restriction

• Restrict dietary sodium to <2,300 mg/day to control blood pressure and reduce cardiovascular risk 3

Other Lifestyle Measures

• Stop smoking 1, 4
• Achieve and maintain healthy weight if overweight or obese 1, 4
• Regular physical exercise 1, 4
• Consider plant-based "Mediterranean-style" diet for cardiovascular protection 3

Medication Safety

Avoid Nephrotoxins

• Never prescribe NSAIDs in CKD patients due to nephrotoxicity, acute kidney injury risk, and worsening heart failure 3, 6, 5
• Review and limit over-the-counter medicines and herbal remedies that may be harmful 3
• Adjust doses of renally cleared medications based on eGFR 3, 5

Monitoring Frequency Based on Risk Stratification

The combination of eGFR and UACR determines progression risk and monitoring intensity 1, 2:

• Low risk (eGFR ≥60 with UACR <30 mg/g): Monitor eGFR and UACR annually 1, 2
• Moderate risk (eGFR 45-59 with UACR <30 mg/g, or eGFR ≥60 with UACR 30-300 mg/g): Monitor 2 times per year 2
• High risk (eGFR 30-44 with any UACR, or eGFR 45-59 with UACR 30-300 mg/g): Monitor 3 times per year 2
• Very high risk (eGFR <30 with any UACR, or any eGFR with UACR >300 mg/g): Monitor 4 times per year and refer to nephrology 2

Nephrology Referral Indications

Refer to nephrology for any of the following 1, 2, 3, 7:

• eGFR <30 mL/min/1.73 m² (CKD stages 4-5) 1, 2, 3, 7
• Continuously increasing albuminuria despite optimal management 1, 2
• Continuously decreasing eGFR or rapid progression (sustained decline ≥5 mL/min/1.73 m²/year) 1, 2
• Uncertainty about etiology or atypical features suggesting non-diabetic kidney disease 1, 2
• Difficulty managing CKD complications (anemia, metabolic bone disease, resistant hypertension, electrolyte disturbances) 1, 2
• Hematuria, pyuria, or casts suggesting glomerulonephritis 2

Common Pitfalls to Avoid

• Do not rely on serum creatinine alone—always calculate eGFR and measure UACR, as both provide independent prognostic information 2
• Do not skip albuminuria testing—eGFR alone misses significant kidney damage and cardiovascular risk 2
• Do not assume small eGFR fluctuations indicate progression—confirm with serial measurements over time 1
• Do not stop ACE inhibitor/ARB for minor creatinine increases (<30%) unless volume depletion is present 1, 2
• Do not prescribe NSAIDs regardless of symptom severity, as they cause nephrotoxicity and accelerate CKD progression 3, 6, 5
• Do not delay nephrology referral when eGFR <30 mL/min/1.73 m², as early referral reduces costs, improves quality of care, and delays dialysis 1, 7