Lippincott Nursing Pocket Card - April 2022

Chronic Kidney Disease


Chronic Kidney Disease

Previously known as chronic renal failure, chronic kidney disease (CKD) is a progressive, irreversible loss of kidney function resulting in reduced filtration, build-up of toxins, and fluid and electrolyte imbalance. Continued decline in kidney function results in end-stage kidney disease (ESKD).


The Kidney Disease: Improving Global Outcomes (KDIGO) workgroup defines CDK as either of the following for at least three months (KDIGO, 2012):
  • Estimated glomerular filtration rate (eGRF) less than 60 mL/min/1.73 m2
  • Markers of kidney damage (one or more)
    • Albuminuria
      • Albumin excretion rate (AER) greater than or equal to 30 mg/24 hours
      • Albumin-to-creatinine ratio (ACR) greater than or equal to 30 mg/g
    • Urine sediment abnormalities
    • Electrolyte and other abnormalities due to tubular disorders
    • Abnormalities detected by histology
    • Structural abnormalities detected by imaging
    • History of kidney transplantation

Classification of CKD

CKD is classified based on cause, GFR category, and albuminuria category (CGA). Cause of CKD is based on presence or absence of systemic disease and the location within the kidney of pathologic-anatomic findings (KDIGO, 2012). GFR reflects total filtration in all functioning nephrons.
Glomerular Filtration Rate (GFR) Categories (KDIGO, 2012)
GFR Category GFR (mL/min/1.73m2) Terms
G1 Greater than or equal to 90 Normal or high
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 Less than 15 Kidney Failure

Protein filtered from the blood is typically reabsorbed in the nephron tubules with minimal amounts excreted in the urine. In CKD, glomerular permeability increases allowing protein to cross back into the urine. Since albumin is the primary protein in the urine of people with CKD, elevated urine albumin is a marker for glomerular disease (Norton et al., 2017a).
Albuminuria Categories in CKD (KDIGO, 2012)
  Albumin Excretion Rate
Urine Albumin (mg)-to-Creatinine (g) Ratio (ACR)
(Approximate Equivalent)
Category  (mg/24 hours) (mg/mmol) (mg/g) Terms
A1 Less than 30 Less than 3 Less than 30 Normal to mildly increased
A2 30-300  3-30 30-300 Moderately increased
A3 Greater than 300 Greater than 30 Greater than 300 Severely increased


Most Common Causes & Risk Factors

Common Causes of CKD Common Risk Factors for CKD
Hypertension  Smoking
Diabetes  Aging
Kidney infection; glomerulonephritis  Hyperlipidemia
Crush injury Gender: more common in males than females
Toxins and medications (i.e., ibuprofen, aspirin, contrast dyes) Race: higher risk in Black, Hispanic, Pacific Islander, and Native American populations
Chronic disorders (i.e., lupus erythematosus, scleroderma) Family history of kidney disease and genetic disorders (i.e., polycystic kidney disease)

Signs and Symptoms

Signs and symptoms will vary based on the stage of the disease. Many patients are asymptomatic until CKD is advanced.
  • Nausea, vomiting
  • Dependent edema
  • Poor appetite, anorexia
  • Dry, itchy skin
  • Weakness, fatigue
  • Decreased urine output, urinary frequency, blood in urine
  • Shortness of breath


Laboratory Tests
  • Electrolytes: sodium, potassium, calcium, chloride, phosphorus, bicarbonate
  • Blood glucose
  • Albumin
  • Blood urea nitrogen (BUN) and creatinine
  • Urinalysis: albuminuria, proteinuria, hematuria
  • Complete blood count
  • Parathyroid hormone, calcitriol
  • Additional tests to rule out glomerular disease, viral infection, or hematologic disorders as clinically indicated
  • Radiocontrast (KDIGO, 2012):
    • Avoid high osmolar agents
    • Use lowest possible radiocontrast dose
    • Withdraw potentially nephrotoxic agents before and after the procedure
    • Hydrate patient with normal saline before, during, and after the procedure
    • Measure GFR 48-96 hours after the procedure
    • Avoid gadolinium-containing contrast media in GFR less than 15 mL/min/1.73m2
  • Ultrasonography of the kidney and perirenal structures – detects kidney tissue damage, kidney stones, urinary tract obstruction or other abnormalities
  • Computed tomography (CT) scan – detects structural abnormalities
  • Renal angiography – examines the blood vessels
Diagnostic Procedures
  • Electrocardiography (ECG) to assess for arrhythmias related to electrolyte imbalance
  • Kidney biopsy to test for malignancy
CKD Complications
Electrolyte imbalances  Fluid overload Hypertension
Metabolic acidosis Hypoalbuminemia Anemia
Uremia Arrhythmias Infection and sepsis
Abnormal mineral metabolism and bone disease 

Treatment & Management
The following measures aim to treat the reversible causes of kidney didease, slow its progression, and treat complications.

  • Control blood pressure; target less than 140/90 mmHg (Norton et al., 2017a).
  • Treat with renin-angiotensin-aldosterone system (RAAS) blockers such as ACE inhibitors and ARBs for the following (KDIGO, 2012):
    • Albuminuria 30-300 mg/24 hours in diabetic adults
    • Albuminuria greater than 300 mg/24 hours in diabetic and nondiabetic adults
  • Manage diabetes (KDIGO, 2012).
    • Target hemoglobin A1c to 7.0% or less than 7% (53 mmol/mol) to prevent or delay progression of diabetes complications
  • Measure hemoglobin to monitor for anemia.
  • Encourage smoking cessation.
  • Encourage weight reduction.
  • Temporarily discontinue nephrotoxic and renally excreted medications if GFR less than 60 mL/min/1.73m2 and increased risk of AKI (KDIGO, 2012; Norton et al., 2017a) such as non-steroidal anti-inflammatory drugs (NSAIDS), diuretics, metformin, lithium, digoxin, quinolones, B-lactam antiobiotics, sulfonamides.
Adjust drug doses for the level of GFR. Examples of common drugs requiring renal dose adjustments include allopurinol, lithium, acyclovir, gabapentin, rivaroxaban (Xarelto), cephalexin, Bactrim, amoxicillin, and levofloxacin.
  • Restrict salt intake (KDIGO, 2012).
    • Goal is less than 90 mmol (2 grams/day), unless contraindicated.
  • Modify protein intake (KDIGO, 2012).
    • Reduce protein intake to 0.8 grams/kg body weight.
    • Avoid high protein intake (greater than 1.3 g/kg/day) in adults with CKD at risk of progression.
  • Recommend high-calorie diet.
  • Avoid foods high in potassium, phosphorus, and sodium.
  • Restrict fluid intake based on urine production.

Kidney replacement therapy (KRT) (Norton et al., 2017b)


  • Initiate when one or more of the following are present (KDIGO, 2012):
    • Signs or symptoms of kidney failure (serositis, acid-base or electrolyte abnormalities, pruritus)
    • Inability to control volume status or blood pressure
    • Progressive decrease in nutritional status unresponsive to dietary intervention
    • Cognitive impairment
  • Dialyzer machine is used to filter waste products from the blood three or more times a week; diffusion efficacy depends on the dialysate solution.
  • Vascular access required
    • Arteriovenous fistula: an artificial connection between an artery and vein diverting blood to the vein; preferred access method
    • Arteriovenous graft: second option if fistula cannot be created
    • In an emergency, temporary vascular access may be obtained in a central vein (i.e., internal jugular) however these are associated with inadequate dialysis, increased infection rates, clotting, and inflammation. 
Peritoneal dialysis
  • The peritoneal membrane is used as a semipermeable filter, replacing the kidneys. A dialysis solution (osmotic agent) is infused into the abdominal cavity through a percutaneous catheter. Through diffusion, waste products are pulled from the blood in the peritoneal capillaries into the dialysate. Following the prescribed dwell time, the solution is drained through the catheter.
  • Efficacy is based on:
    • Concentration gradient
    • Size of the solute
    • Permeability of the peritoneal membrane
  • Restrict potassium intake.
  • Replace amino acids.
  • Increase dietary proteins.
  • Monitor glucose closely; insulin may be added to dialysis solution.
Kidney transplant        
  • Living donor renal transplantation should be considered when GRF is less than 20 mL/min/1.73m2 and there is evidence of progressive and irreversible CKD over the preceding 6-12 months (KDIGO, 2012).
Conservative Management (KDIGO, 2012)
  • Option for people who choose not to pursue KRT
  • Advance care planning and end-of-life care
  • Include protocols for dietary restrictions, symptom and pain management, psychological care, spiritual care, culturally sensitive care and bereavement support.

Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. (2012). KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney International., Suppl. 2013; 3: 1–150.
Norton, J. M., Newman, E. P., Romancito, G., Mahooty, S., Kuracina, T., & Narva, A. S. (2017a). Improving Outcomes for Patients with Chronic Kidney Disease: Part 1. The American Journal of Nursing117(2), 22–32.
Norton, J. M., Newman, E. P., Romancito, G., Mahooty, S., Kuracina, T., & Narva, A. S. (2017b). Improving Outcomes for Patients with Chronic Kidney Disease: Part 2. The American Journal of Nursing117(3), 26–35.