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Chronic Kidney Disease: Prevention, Diagnosis, and Treatment

Andrew J. Goodbred, MD
Robert C. Langan, MD

American Family Physician. 2023;108(6):554-561.

Author disclosure: No relevant financial relationships.

Chronic kidney disease (CKD) affects approximately 15% of the U.S. population, and many people are unaware of their diagnosis. Screening may be considered for patients with cardiovascular disease, diabetes mellitus, hypertension, age 60 years and older, family history of kidney disease, previous acute kidney injury, or preeclampsia. Diagnosis and staging of CKD are based on estimated glomerular filtration rate (eGFR), excessive urinary albumin excretion, or evidence of kidney parenchymal damage lasting more than three months. eGFR should be determined using the CKD-EPI creatinine equation without the race variable. Risk calculators are available to estimate the risk of progression to end-stage renal disease. When possible, serum cystatin C should be measured to confirm eGFR in patients with CKD. Blood pressure should be maintained at less than 140/90 mm Hg, with a systolic blood pressure target of 120 mm Hg or less for patients tolerant of therapy, using an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker. Sodium-glucose cotransporter-2 inhibitors and metformin should be considered in patients with CKD and type 2 diabetes who have not reached their glycemic goal. Intravenous iodinated contrast media temporarily reduces eGFR and should be avoided in patients with advanced CKD. Interdisciplinary management of patients with CKD is important for reducing morbidity and mortality, and patients at high risk of progression to end-stage renal disease should be referred to a nephrologist.

Chronic kidney disease (CKD) affects about 15% of the U.S. population; however, 9 out of 10 people do not know they have impaired renal function.1 CKD is diagnosed in Black people three times as often as in White people.1,2 CKD is more common in women than men, but men are more likely to progress to end-stage renal disease (ESRD).1,2 CKD is more common in patients 60 years and older compared with younger patients, and more advanced disease is associated with an increased risk of cardiovascular disease and death.1,3

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating Comments
Stage patients with CKD using the CKD-EPI creatinine equation without the race variable and measure a first-morning urine sample for albumin/creatinine ratio to test for albuminuria.6,8 C Recommendation from the National Kidney Foundation/American Society of Nephrology based on broader applicability and clinical performance
Measure serum cystatin C when available to confirm estimated glomerular filtration rate in patients with CKD, because combining it with the CKD-EPI creatinine equation is more accurate than using either method alone.6,7 C Recommendation from the National Kidney Foundation/American Society of Nephrology due to improved accuracy
Recommend lifestyle interventions for preventing and managing CKD, including dietary sodium intake of less than 2,300 mg per day, moderate-intensity exercise of at least 150 minutes per week, and smoking cessation.5,13 C Recommendation from the VA/DoD and KDIGO CKD Work Group based on observational studies
Manage systolic blood pressure to a target of ≤ 120 mm Hg in patients with CKD if tolerated.26,27 B Recommendation from high-quality RCT and KDIGO CKD Work Group guideline
Prescribe sodium-glucose cotransporter-2 inhibitors and metformin as first-line therapy in patients who have CKD stages 1 to 3 and type 2 diabetes mellitus.35 C Recommendation from KDIGO CKD Work Group based on large RCTs
Measure serum hemoglobin levels at least annually in patients with CKD stage 3 or greater, and as indicated in those with less severe disease.41 C Recommendation from KDIGO CKD Work Group
For patients with CKD stages 3a to 5, obtain serum measurements of calcium, phosphate, 25-hydroxyvitamin D, and parathyroid hormone to evaluated for bone mineral disorders.42 C Recommendation from KDIGO CKD Work Group
Use iodinated contrast selectively in patients with CKD stage 3 or greater, and consider pre- and postprocedural hydration if used.13 C Recommendation from VA/DoD based on prospective cohort studies

CKD = chronic kidney disease; CKD-EPI = Chronic Kidney Disease Epidemiology Collaboration; KDIGO = Kidney Disease: Improving Global Outcomes; RCT = randomized controlled trial; VA/DoD = Department of Veterans Affairs/Department of Defense.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

ANDREW J. GOODBRED, MD, FAAFP, is the program director of St. Luke’s Family Medicine Residency–Anderson, Easton, Pa., and an adjunct professor in the Department of Family and Community Medicine at the Lewis Katz School of Medicine at Temple University, Philadelphia, Pa.

ROBERT C. LANGAN, MD, FAAFP, is the program director of St. Luke’s Family Medicine Residency–Sacred Heart, Allentown, Pa., and an adjunct professor in the Department of Family and Community Medicine at the Lewis Katz School of Medicine at Temple University.

Address correspondence to Andrew J. Goodbred, MD, 1700 St. Luke’s Blvd., MOB Ste. 402, Easton, PA 18045 (andrew.goodbred@sluhn.org). Reprints are not available from the authors.

Author disclosure: No relevant financial relationships.

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