Chronic kidney disease
Adults with CKD who are not on dialysis and have no kidney transplant. Not for acute kidney injury, dialysis or transplant care. Anemia, bone disease and acidosis care are not covered here; for ferritin cutoffs in CKD, see Anemia.
Screening
- KDIGO Kidney Disease: Improving Global Outcomes
| Decision | Guideline |
|---|---|
| Who | People at risk: Hypertension, diabetes, cardiovascular disease including heart failure, prior acute kidney injury. Also consider
|
| Test | Both urine ACR and eGFR. |
| How often | No evidence-based interval for people at risk.Type 2 diabetes: Yearly, from diagnosis. Type 1 diabetes: Yearly, from 5 years after diagnosis. See Diabetes follow-up. |
Diagnose
- KDIGO Kidney Disease: Improving Global Outcomes
| Decision | Guideline |
|---|---|
| Criteria | GFR under 60 mL/min/1.73 m², or one or more markers of kidney damage. Markers of damage
|
| Classify | Cause, GFR category (G1-G5) and albuminuria category (A1-A3). |
| GFR categories | GFR in mL/min/1.73 m²
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| Albuminuria categories | Urine ACR in mg/mmol
|
| Confirm | Repeat the tests before calling it CKD after an incidental raised ACR, hematuria or low eGFR.Confirm a random ACR of 3 mg/mmol or more on a first morning sample. |
| Chronicity | One abnormal eGFR or ACR is not CKD. It may be acute kidney injury. After recovery from acute kidney injury, wait 3 months after discharge before diagnosing CKD. |
| Older adults | The threshold stays GFR under 60, even with ACR under 3 mg/mmol. |
| eGFR | Creatinine-based eGFR first, from a validated equation, not creatinine alone.Add Cystatin C (eGFRcr-cys) when creatinine-based eGFR is less accurate and GFR affects a decision. Do not use race in the eGFR. |
Investigate
- KDIGO Kidney Disease: Improving Global Outcomes
| Decision | Guideline |
|---|---|
| Cause | Establish the cause.
|
| Real change | A change in eGFR over 20% exceeds the expected variability and needs evaluation.After starting a hemodynamically active drug: A fall over 30%. ACR: A doubling. |
| Kidney failure risk | G3-G5: Use a validated risk equation, such as the kidney failure risk equation at kidneyfailurerisk.com opens in a new tab.5-year risk 3-5%: Consider nephrology referral. 2-year risk over 10%: Multidisciplinary care. 2-year risk over 40%: Prepare for kidney replacement therapy. |
| Cardiovascular risk | Use a validated model that includes eGFR and albuminuria to guide prevention.For the Québec lipid pathway, see Hyperlipidemia. |
Treat
- KDIGO Kidney Disease: Improving Global Outcomes
- INESSS Institut national d'excellence en santé et services sociaux
- CCS Canadian Cardiovascular Society
| Decision | Guideline |
|---|---|
| Everyone | Healthy, diverse diet, with more plant-based than animal-based foods and less ultra-processed food.Moderate-intensity physical activity, at least 150 minutes a week, as tolerated. No tobacco. Consider weight loss with obesity. |
| Blood pressure target | Québec: Systolic under 130. CKD (eGFR under 60 or urine ACR 3 mg/mmol or more) is a high cardiovascular risk condition.
No diastolic target once the systolic target is met.
The target may be adjusted for frailty or risk of falls.
See Hypertension. KDIGO: Systolic under 120 when tolerated, with standardized office BP.Less intensive with frailty, high risk of falls and fractures, very limited life expectancy, or symptomatic postural hypotension. |
| ACE inhibitor or ARB | Start an ACE inhibitor or angiotensin receptor blocker (ARB) by albuminuria and diabetes.
|
| ACE inhibitor or ARB, keep | Continue when eGFR falls below 30.
|
| Never | Do not combine an ACE inhibitor, an ARB or a direct renin inhibitor. |
| SGLT2 inhibitor | Recommended in adults with CKD in these cases.
Suggested
Continue
|
| Nonsteroidal MRA | Suggested with type 2 diabetes, eGFR over 25, normal potassium, and ACR over 3 mg/mmol despite the maximum tolerated ACE inhibitor or ARB.Can be added to an ACE inhibitor or ARB and an SGLT2 inhibitor. Choose an agent with proven kidney or cardiovascular benefit. |
| Statin, Canada | CKD is a statin indication, except with chronic dialysis.CKD here means eGFR under 60, or ACR 3 mg/mmol or more, for at least 3 months.
The CCS primary prevention tool (October 2026) adds age 50 or older. CCS 2021 opens in a new tabCCS tool 2026 opens in a new tabKDIGO 2024 opens in a new tab |
| Drug dosing | Consider GFR when dosing drugs cleared by the kidneys.
|
| Child-bearing potential | |
| Prescribing | Review each drug's teratogenic potential.
|
Follow-up
- KDIGO Kidney Disease: Improving Global Outcomes
| Decision | Guideline |
|---|---|
| Labs | Urine ACR and eGFR at least yearly.
|
| After starting or raising an ACE inhibitor or ARB | BP, creatinine and potassium within 2-4 weeks. |
| Creatinine up over 30% within 4 weeks | Look for the cause first.
|
| Hyperkalemia on an ACE inhibitor or ARB | Lower the potassium first, rather than reducing or stopping the drug.Review other drugs. Moderate dietary potassium. Consider a diuretic, sodium bicarbonate or a potassium binder. |
| Nonsteroidal MRA | Check potassium regularly after starting. |
| Sick days and surgery | Withhold an SGLT2 inhibitor during prolonged fasting, surgery or critical illness.Elective surgery: Consider stopping Metformin, ACE inhibitor, ARB and SGLT2 inhibitor 48-72 h before. Give a clear restart plan and document it. |
| Contrast | IV iodinated contrast at GFR under 60: Follow radiology society consensus statements. Gadolinium at GFR under 30: Prefer American College of Radiology group II or III agents. |
| Refer | |
| Cause | Cause uncertain, hereditary kidney disease, or recurrent extensive kidney stones. |
| Kidney function | GFR under 30, or a 5-year kidney failure risk over 3-5%.A sustained fall in GFR over 20%, or over 30% after starting a hemodynamically active drug. |
| Urine | ACR 30 mg/mmol or more with hematuria.
|
| Complications | Hypertension refractory to 4 or more drugs.
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| Plan kidney replacement | Plan transplant or dialysis access at GFR under 15-20, or a 2-year kidney failure risk over 40%. |
| Children | |
| Refer | Refer to specialist kidney care in any of these cases.
|
Reviewed 18 October 2026 against the official sources below.
Sources
Blue square: Québec · red round: Canada · grey round: international. The code names the body; each section's key gives its full name.