Chronic kidney disease

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 10 Aug 2025

Last updated: 22 Aug 2025

Chronic kidney disease (CKD) is a common condition that is often unrecognized until the most advanced stages.

Diagnosis is determined by laboratory studies: proteinuria or hematuria, and/or a reduction in the glomerular filtration rate, of more than 3 months' duration.

Comorbidity is common and should always be considered in the diagnosis and management of people with CKD. Diabetes mellitus and hypertension are the most common causes of CKD and the most common comorbidities associated with CKD; they both lead to and complicate CKD.

Glycemic control for diabetic kidney disease and optimization of blood pressures are key in slowing the progression of the disease. Use of agents that block the renin-angiotensin system and sodium-glucose cotransporter-2 (SGLT2) inhibitors have kidney function-preserving benefits that are independent of blood pressure and glucose control.

CKD is a risk factor for cardiovascular disease, independent of comorbidities such as diabetes, hypertension, and dyslipidemia.

Definition

CKD, also known as chronic renal failure, is defined as abnormalities of kidney structure or function, present for ≥3 months, with implications for health.[1] In practice, this means a glomerular filtration rate less than 60 mL/minute/1.73 m², or the presence of one or more of the following markers of kidney damage: albuminuria (albumin to creatinine ratio [ACR] ≥30 mg/g), urine sediment abnormalities, persistent hematuria, electrolyte and other abnormalities due to tubular disorders, abnormalities detected by histology, structural abnormalities detected by imaging, or history of kidney transplantation.[1]

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History and exam

Key diagnostic factors

fatigue
edema
nausea with/without vomiting
pruritus
skin and nail changes
restless legs
anorexia
infection-related glomerular disease

Full details

Other diagnostic factors

arthralgia
enlarged prostate gland
foamy-appearing urine
cola- or tea-colored urine
rashes
dyspnea
orthopnea
seizures
retinopathy

Full details

Risk factors

diabetes mellitus
hypertension
age >50 years
childhood kidney disease
smoking
obesity
non-Hispanic black ethnicity
family history of CKD
autoimmune disorders
male sex
long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs)
high uric acid levels

Full details

Diagnostic tests

1st tests to order

renal chemistry
estimation of GFR using serum creatinine
estimation of GFR using cystatin C with or without serum creatinine
urinalysis
urinary albumin
renal ultrasound

Full details

Tests to consider

kidney biopsy
plain abdominal radiograph
diabetes screen
mineral bone disorder assessment
anemia assessment

Full details

Emerging tests

genetic testing

Treatment algorithm

ACUTE

GFR category G1 to G2

GFR category G3 to G4

GFR category G5

Contributors

Authors

Manisha Singh, MD

Associate Professor

Division of Nephrology

Department of Internal Medicine

Director Home Dialysis Program

Co-Director M2 Renal Module

University of Arkansas for Medical Sciences

Little Rock

Disclosures

MS is an author of a reference cited in this topic.

Michelle W. Krause, MD, MPH

Professor of Medicine

Director, Integrated Medicine Service Line

Vice-Chair for Clinical Operations, Quality, and Efficiency

Department of Internal Medicine

University of Arkansas for Medical Sciences

Central Arkansas Veterans Healthcare System

Little Rock

Disclosures

MWK declares that she has no competing interests.

Acknowledgements

Dr Manisha Singh and Dr Michelle Krause would like to gratefully acknowledge Professor Sudhir V. Shah, a previous contributor to this topic.

Disclosures

SVS declares that he has no competing interests.

Peer reviewers

Robert Toto, MD

Professor

Internal Medicine - Nephrology

Southwestern Medical School

The University of Texas Southwestern Medical Center at Dallas

Dallas

Disclosures

RT declares that he has no competing interests.

Guy H. Neild, MD, FRCP, FRCPath

Professor of Nephrology

UCL Division of Medicine

University College London

London

Disclosures

GHN declares that he has no competing interests.

Peer reviewer acknowledgements

BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.

Disclosures

Peer reviewer affiliations and disclosures pertain to the time of the review.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2024 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int. 2024 Apr;105(4s):S117-314.Full text Abstract

National Institute for Health and Care Excellence. Chronic kidney disease: assessment and management. Nov 2021 [internet publication].Full text

Wong-You-Cheong JJ, Nikolaidis P, Katri G, et al; Expert Panel on Urologic Imaging. ACR appropriateness criteria® renal failure. J Am Coll Radiol. 2021 May;18(5s):S174-88.Full text Abstract

Kalantar-Zadeh K, Jafar TH, Nitsch D, et al. Chronic kidney disease. Lancet. 2021 Aug 28;398(10302):786-802. Abstract

Kidney Disease: Improving Global Outcomes (KDIGO) CKD-MBD Work Group. KDIGO 2017 clinical practice guideline update for the diagnosis, evaluation, prevention, and treatment of chronic kidney disease-mineral and bone disorder (CKD-MBD). Kidney Int Suppl. 2017 Jul;7(1):1-59.Full text

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials
- Acute kidney injury
- Diabetic kidney disease
- Hypertensive nephrosclerosis
More Differentials
Guidelines
- KDIGO clinical practice guideline for the evaluation and management of chronic kidney disease
- Chronic kidney disease and risk management: standards of care in diabetes - 2024
More Guidelines
Patient information
Chronic kidney disease: what is it?
Chronic kidney disease: what are the treatment options?
More Patient information
Calculators
Glomerular Filtration Rate Estimation (eGFR) by Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) Equation with Creatinine, without Race (2021)
Glomerular Filtration Rate Estimation (eGFR) by CKD-EPI Equation with Cystatin C, without Race (2012)
More Calculators
Videos
Venepuncture and phlebotomy: animated demonstration
More videos
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Chronic kidney disease

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic tests

1st tests to order

Tests to consider

Emerging tests

Treatment algorithm

GFR category G1 to G2

GFR category G3 to G4

GFR category G5

Contributors

Authors

Manisha Singh, MD

Disclosures

Michelle W. Krause, MD, MPH

Disclosures

Acknowledgements

Disclosures

Peer reviewers

Robert Toto, MD

Disclosures

Guy H. Neild, MD, FRCP, FRCPath

Disclosures

Peer reviewer acknowledgements

Disclosures

References

Key articles

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials

Guidelines

Patient information

Calculators

Videos

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice