Advancing kidney disease

• Monitor trends in eGFR and ACR
• Identify patients with rapid progression who may require specialist input.
• Review potentially reversible causes of deterioration.

• Cardiovascular disease remains the leading cause of morbidity and mortality in CKD.
• Optimise:
  • blood pressure,
  • lipid management,
  • diabetes care,
  • smoking cessation, weight management, and physical activity.

• Regularly review medicines for efficacy, safety, and dose appropriateness.
• Avoid or minimise nephrotoxic medications where possible.
• Consider the need for dose adjustment as kidney function declines.

Prevalence of renal anaemia increases as eGFR decreases, and is uncommon when eGFR is >40mls/min. For renal anaemia, treatment of anaemia has been shown to improve quality of life in patients with CKD.

Detailed guidance can be found in the UKKA anaemia of CKD clinical practice guideline.

Hyperkalaemia is a relatively common complication of CKD, largely in stages G4 and G5. It can also result from, or be exacerbated by, frequently used renal medications such as ACE inhibitors and finerenone. Hyperkalaemia can also occur if there is acute kidney injury (AKI) in addition to CKD.

• Specialist dietician advice should be sought to support patients with chronic hyperkalaemia to eat a low potassium diet
• Consider correcting concurrent metabolic acidosis as this may contribute to normalising serum potassium
• Consider correcting constipation
• It is often in the patient’s best interests to continue, or to restart, medications with disease modifying benefits such as ACE inhibitors and angiotensin receptor blockers, even with a history of hyperkalaemia. Potassium binding agents including sodium zirconium cyclosilicate (lokelma) and patiromer calcium (veltassa) can be helpful to facilitate this.

As kidney function declines, the capacity to excrete acid decreases, resulting in acid retention and a fall in serum bicarbonate concentration. Persistent metabolic acidosis is associated with adverse outcomes, including CKD progression, muscle wasting, and impaired bone health. Sodium bicarbonate tablets or capsules should be started to correct acidosis and dose adjusted to maintain bicarbonate levels between 22-26 mEq/L. Gastro-resistant sodium bicarbonate capsules should be considered in patients who develop GI intolerance to normal release formulations.

As kidney function declines, particularly in CKD stages G4-G5, disturbances in phosphate, calcium, vitamin D and parathyroid hormone (PTH) can develop. Collectively, these abnormalities are known as CKD-mineral and bone disorder (CKD-MBD) and are associated with an increased risk of fractures, cardiovascular disease, and mortality.

• Be aware that CKD-MBD becomes more common as CKD advances.
• Correct vitamin D deficiency where appropriate
• Monitor calcium, phosphate and vitamin D in line with local guidance and specialist recommendations.
• Unexplained bone pain, fragility fractures, or abnormal biochemical markers may indicate CKD-MBD.
• Patients with advanced CKD often have complex mineral and bone disorders requiring specialist input.

Fluid overload becomes more common as CKD progresses, particularly in CKD G4-G5.Symptoms may develop gradually and can significantly impact quality of life.Fluid overload is associated with increased cardiovascular morbidity and hospitalisation. Look out for:

• Peripheral oedema (ankle, leg or sacral)
• Increasing breathlessness, particularly on exertion
• Orthopnoea or nocturnal breathlessness
• Rapid weight gain
• Raised blood pressure
• Elevated jugular venous pressure (JVP)
• Pulmonary crackles on chest examination

Manage via:

• restrict dietary sodium (where appropriate)
• assess volume status and fluid restricting (where appropriate)
• review medications that may contribute to fluid retention
• consider diuretic therapy (where clinically appropriate). Note patients with CKD G4/5 may require high doses of furosemide (250-500mg per day) to maintain fluid balance

Fatigue, breathlessness, pain, itch, poor sleep, anxiety, and depression are common and can substantially affect physical functioning, emotional wellbeing, and quality of life. Routine assessment of symptoms should form part of holistic CKD care.

Restless legs syndrome (RLS) and muscle cramps are common but often under-recognised symptoms of CKD, particularly in advanced disease. Both can significantly disrupt sleep, contribute to fatigue, impair daily functioning, and reduce quality of life.

• Restless legs syndrome is characterised by an uncomfortable urge to move the legs, typically occurring during periods of rest and worsening in the evening or at night. Symptoms may be described as aching, crawling, tingling, itching, or a “creeping” sensation that is temporarily relieved by movement. CKD, iron deficiency, anaemia, and sleep disorders are recognised risk factors.
• Muscle cramps, particularly nocturnal leg cramps, are also frequently reported by people with CKD. They may be related to uraemia, electrolyte abnormalities, fluid shifts, medication effects, or other comorbidities. Symptoms can range from occasional discomfort to severe pain that disrupts sleep and physical activity.

People living with CKD often experience symptoms and complications that contribute to frailty, including fatigue, sarcopenia (loss of muscle mass and strength), anaemia, poor nutrition, reduced physical activity, and multiple medication use. The presence of frailty may influence treatment decisions, the balance of risks and benefits of interventions, and an individual’s ability to self-manage their condition. Routinely assess for frailty in patients with advanced CKD and use the findings to support personalised care planning. Management should focus on maintaining independence, optimising symptom control, reducing treatment burden, reviewing medications, supporting nutrition and physical activity, and ensuring care aligns with the patient’s goals and preferences.

During the consultation:

• Proactively ask about symptoms of advancing kidney disease
• Document frailty score in patient records (where appropriate)
• Assess for potentially reversible causes e.g iron deficiency anaemia, acidosis, sleep hygiene etc.
• encourage self- management strategies (where appropriate)

• Discuss patient goals, priorities, and preferences early.
• Support self-management and ensure patients understand their condition and treatment options.

The majority of the people living with CKD will not progress to end-stage kidney disease or require kidney replacement therapy such as dialysis or kidney transplantation.

For people approaching kidney failure:

• Consider timely referral to specialist kidney services taking the patient’s wishes into account
• Discuss future treatment options, including kidney replacement therapy and conservative kidney management (where appropriate).
• Ensure patients have access to education and decision support. Signpost to high quality information via reputable websites such as Kidney Care UK, National Kidney Foundation, UK Kidney Association, Diabetes UK, British Heart Foundation. Allow time or them to fully understand and make informed choices about their treatment.

• For frail patients or those with significant comorbidity, discuss advance care planning as part of personalised care.
• Consider treatment burden, quality of life, and future healthcare preferences when making management decisions.
• Encourage early conversations about goals of care, including preferences for future treatment and place of care where appropriate.
• Ensure advance care planning discussions are documented and shared through local systems, including the Universal Care Plan (UCP) where available, to support coordinated, person-centred care across healthcare settings.