CKD and the cardiorenal axis
Finding and confirming chronic kidney disease, the KDIGO 2024 heat map, and the primary-care ladder that now protects the kidney and the heart together: blood pressure and RAAS blockade, an SGLT2 inhibitor for CKD with or without diabetes, finerenone, the GLP-1 receptor agonist after FLOW, the statin, and the referral rules. About 60 minutes, for GPs, GP trainees, pharmacists, nurses, advanced clinical practitioners and physician associates. A 10-item knowledge check is marked on our learning platform; pass at 70% and a numbered, verifiable Certificate of CPD (1 hour) from New Vision University (UK) is issued to you.
Living Certificate · reviewed and kept current
Last editorial review: awaiting clinical sign-off · Next scheduled refresh: 12 months after sign-off.
The Golden Triangle for the topic taught here: fixed to the topic, and re-examined when its knowledge, evidence or real-world sources change.
Golden Triangle
Chronic kidney disease
Knowledge Green · Evidence Green · Real-world Red
Not yet at the Equinox · UK (NHS England) · as of 7 October 2026 · How the triangle works
A 61-year-old man whose "borderline kidney function" was never coded
Mr P, 61, has type 2 diabetes (HbA1c 58 mmol/mol on metformin), hypertension on amlodipine, and a BMI of 32. His annual bloods show an eGFR of 54 mL/min/1.73 m²; the two previous years read 58 and 56, each filed as "borderline, no action". Nobody has measured a urine albumin:creatinine ratio. The practice pharmacist, working through the uncoded-CKD search, requests one: ACR 9 mg/mmol, confirmed on a second early-morning sample.
That makes CKD G3a A2: a persistent eGFR of 45–59 with moderately increased albuminuria, in the high-risk band of the KDIGO 2024 heat map. It is coded, and the ladder begins. Amlodipine gives way to ramipril, titrated to 10 mg with U&E after each step; dapagliflozin 10 mg is added for the kidney and the heart, and the expected 4 mL/min dip in eGFR at three weeks is explained, not acted on. With potassium 4.5 mmol/L and albuminuria persisting, finerenone 10 mg follows under NICE TA877. He is already on atorvastatin 20 mg; the non-HDL cholesterol is rechecked. His five-year kidney failure risk is about 1%, so he stays in primary care, with eGFR and ACR twice a year, a sick-day card and a lifestyle plan. That ladder, in six lessons, is this module.
By the end of this module you will be able to…
Finding and confirming CKD
Who to test, how to confirm chronicity, when cystatin C helps, and the KDIGO 2024 heat map that sets monitoring and treatment.
Who to test, and with what
NICE NG203 (1.1.21) offers an eGFR and a urine albumin:creatinine ratio to adults with diabetes, hypertension, cardiovascular disease, previous acute kidney injury, structural renal tract disease or recurrent stones, multisystem disease that may involve the kidney (for example lupus), gout, a family history of kidney failure or hereditary kidney disease, or incidental haematuria or proteinuria. It advises at least annual GFR monitoring for people taking lithium, calcineurin inhibitors or long-term NSAIDs (1.1.20). KDIGO 2024 likewise advises testing both albuminuria and GFR in people at risk. Use an early-morning sample for the ACR and avoid meat for 12 hours before the creatinine.
Confirming chronicity
Three rules. (1) CKD is an abnormality of kidney structure or function present for more than three months, so a single reduced eGFR or raised ACR is repeated within 2 weeks to exclude an acute change (NG203 1.1.8) and confirmed over more than three months, with at least three estimates over 90 days or more (1.3.6); an ACR of 3–70 mg/mmol is repeated on an early-morning sample (1.1.12) before coding. (2) Creatinine-based eGFR over-states kidney function in people with low muscle mass (CKD can be missed) and under-states it with high muscle mass or recent meat intake (CKD can be over-diagnosed); NG203 (1.1.3) advises interpreting it with caution at extremes of muscle mass. NG203 (2021) removed its earlier cystatin C recommendations; KDIGO 2024 recommends eGFRcr-cys where creatinine-based eGFR is likely to be inaccurate (for example amputation, sarcopenia, bodybuilders) and the result will change decisions (Rec 1.2.2.1, 1C). (3) A fall in eGFR of 25% or more with a change of category, or of 15 or more within 12 months, is accelerated progression and a referral criterion in its own right.
The KDIGO 2024 heat map
| GFR category (mL/min/1.73 m²) | A1 · ACR < 3 mg/mmol | A2 · 3–30 mg/mmol | A3 · > 30 mg/mmol |
|---|---|---|---|
| G1 ≥ 90 · G2 60–89 | Not CKD unless other evidence of damage · annual | Moderately increased · annual | High · twice a year |
| G3a 45–59 | Moderately increased · annual | High · twice a year | Very high · three times a year |
| G3b 30–44 | High · twice a year | Very high · three times a year | Very high · three times a year |
| G4 15–29 | Very high · three times a year (four or more with A3), usually with nephrology; prepare for kidney failure care when the risk warrants it | ||
| G5 < 15 | Kidney failure · four or more times a year with nephrology | ||
Frequencies are from the KDIGO 2024 monitoring heat map (a guide); NICE NG203 Table 2 minimums are lower. Code the GFR and albuminuria category together (for example "CKD G3a A2"); the albuminuria category is what most changes treatment.
Checkpoint 1 · A 72-year-old woman has a first eGFR of 56 and an ACR of 1.8 mg/mmol. Can CKD be coded?
Not yet. Repeat the eGFR within 2 weeks to exclude an acute change and confirm persistence over more than 3 months (at least three estimates over 90 days or more) before coding.
The foundation of the ladder: blood pressure and RAAS blockade
Targets by albuminuria, who gets an ACE inhibitor or ARB, the creatinine and potassium rules, and the nephrotoxins to remove.
Targets
NICE NG203 and NG136: clinic blood pressure below 140/90 (systolic 120–139) for CKD with an ACR under 70 mg/mmol, including type 2 diabetes; below 130/80 (systolic 120–129) for an ACR of 70 or more, and in type 1 diabetes with an ACR of 70 or more. KDIGO 2021 suggests a systolic below 120 mmHg with standardised measurement where tolerated (2B). Measure standing pressure in older and frail patients and let symptoms set the ceiling.
Who gets an ACE inhibitor or ARB
Everyone with CKD and an ACR of 70 mg/mmol or more; over 30 with hypertension; 3 or more with diabetes. Titrate to the maximum tolerated dose, which is where the albuminuria benefit lives. Without diabetes and with an ACR of 70 or more, refer for nephrology assessment as well. Not both together.
The creatinine rule
Check U&E 1–2 weeks after starting or increasing. A creatinine rise of up to 30% (eGFR fall up to 25%) is haemodynamic and expected: continue and recheck. A larger change: hold, look for dehydration, NSAIDs and renal artery disease, and seek advice.
The potassium rule
NICE NG203: do not routinely start a RAS inhibitor if potassium is above 5.0 mmol/L; stop it if potassium reaches 6.0 or more once other potassium-raising drugs have been stopped. In CKD G3b–G5 or heart failure with persistent hyperkalaemia limiting RAAS blockade, a binder can be used: sodium zirconium cyclosilicate (TA1148, potassium 5.5 or more) or patiromer (TA623, 6.0 or more).
Remove what harms. Use NSAIDs with caution (NG203 1.3.10): avoid regular or prolonged use, especially with a RAS inhibitor and a diuretic, monitor eGFR and review over-the-counter use; review lithium levels, avoid trimethoprim with RAAS blockade where potassium is borderline, and dose-adjust by eGFR: metformin reviewed below 45 and stopped below 30; sulfonylurea hypoglycaemia risk rises; direct oral anticoagulants, gabapentinoids and opioids need dose checks. Give every patient written sick-day rules (standard sick-day guidance; follow your local protocol): pause the ACE inhibitor or ARB, diuretic, SGLT2 inhibitor, metformin and NSAIDs during vomiting, diarrhoea or fever with poor intake; restart within 24–48 hours of eating and drinking normally. ACE inhibitors and ARBs should be avoided in pregnancy, and finerenone should not be used unless the woman's clinical condition requires it (MHRA, SmPCs and BNF; Kerendia SmPC 4.4 and 4.6); ask about contraception and pre-conception plans in women of childbearing potential. NG203 1.6.12 advises seeking specialist advice from a kidney physician if the person asks about contraception.
Lifestyle is the base of the ladder: salt below 5 g a day (KDIGO 2024 sodium guidance), physical activity on most days, weight management, smoking cessation and alcohol within limits. Dietary potassium advice is individualised rather than blanket restriction. Advise against potassium-based salt substitutes (for example LoSalt) in anyone on an ACE inhibitor, ARB or MRA, and especially on finerenone.
Checkpoint 2 · Two weeks after starting ramipril, creatinine has risen from 118 to 140 µmol/L (19%), K⁺ 4.8, BP 128/78, no symptoms. What now?
Continue ramipril and recheck creatinine and potassium in 2 weeks. The rise is within the 30% that NICE accepts as the expected haemodynamic effect. Stopping would lose the kidney protection.
The SGLT2 inhibitor in CKD, with or without diabetes
KDIGO 2024, NICE TA1075 and TA942, the eGFR dip, the stop rules, and the 17% problem.
DAPA-CKD (2020) and EMPA-KIDNEY (2023) showed that an SGLT2 inhibitor slows kidney-disease progression in CKD whether or not the patient has diabetes; DAPA-CKD also reduced cardiovascular death or heart-failure hospitalisation and all-cause death, and pooled analyses support fewer heart-failure admissions. KDIGO 2024 recommends one for adults with CKD and eGFR of 20 or more with an ACR of about 22.6 mg/mmol (200 mg/g) or more, for CKD with type 2 diabetes or heart failure irrespective of albuminuria, and suggests it for eGFR 20–45 with lower albuminuria.
NICE criteria
Dapagliflozin (TA1075) and empagliflozin (TA942) are recommended as an add-on to optimised standard care, including the maximum tolerated ACE inhibitor or ARB unless contraindicated. On the same criteria: eGFR 20 to below 45 regardless of albuminuria, or eGFR 45–90 with an ACR of 22.6 mg/mmol or more or type 2 diabetes. Where both are suitable, use the least expensive (rec 1.2); check the current Drug Tariff. Heart failure is a separate SGLT2-inhibitor indication (KDIGO 2024 Rec 3.7.2; NG106). 10 mg once daily; no titration.
Practicalities
Expect an eGFR dip of 3–5 mL/min in the first weeks that plateaus; do not stop for it. Once started, continue even if the eGFR later falls below 20, until dialysis or transplantation. Counsel on genital and urinary infection, volume depletion (reduce the loop diuretic if euvolaemic), foot care in diabetes, ketoacidosis (which can occur with only moderately raised glucose: stop and assess if nausea, vomiting, abdominal pain or breathlessness) and Fournier's gangrene (genital or perineal pain, tenderness, redness or swelling with fever or malaise: seek urgent care). Pause during acute illness with poor intake, and omit on the day before and the day of surgery (UK perioperative consensus, Anaesthesia 2025; KDIGO 2024 PP 3.7.2).
The 17% problem. In UK primary-care data to December 2022, only 17% of adults with CKD and a guideline indication were prescribed an SGLT2 inhibitor (22% with type 2 diabetes, under 0.1% without; Forbes et al., eClinicalMedicine 2024;68:102426, reviewed in Varma and Ravindran, InnovAiT 2026). Prescribing has probably risen since; check your own list. The search in Lesson 6 finds them; the clinic prescribes from the list. ESC/ERA 2026 gives a class I A recommendation for an SGLT2 inhibitor in CKD with type 2 diabetes (eGFR 20 or more) and in CKD without diabetes with eGFR 20 or more and uACR 20 mg/mmol or more (class IIa for eGFR 20–44 with lower albuminuria).
Checkpoint 3 · A 64-year-old man without diabetes has IgA nephropathy, eGFR 36, ACR 90 mg/mmol on ramipril 10 mg. What is missing?
An SGLT2 inhibitor. He meets the KDIGO 2024 and NICE TA942/TA1075 criteria without diabetes; finerenone has no licence or NICE recommendation for CKD outside type 2 diabetes (TA877); its heart-failure indication does not apply here, and ramipril continues.
Finerenone and the GLP-1 receptor agonist in type 2 diabetes with CKD
The sequence after the SGLT2 inhibitor: eligibility, dosing and potassium for finerenone; what FLOW changed for semaglutide.
Finerenone · NICE TA877 and the Kerendia SmPC
NICE TA877: stage 3–4 CKD with albuminuria in type 2 diabetes, as an add-on to optimised standard care (maximum tolerated ACE inhibitor or ARB, and an SGLT2 inhibitor unless contraindicated), with eGFR of 25 or more. Dosing, from the SmPC: start with potassium at or below 4.8 mmol/L (4.9–5.0 may be considered with extra potassium checks in the first 4 weeks; above 5.0 do not start) at 10 mg daily for eGFR 25–59; not recommended below 25. Recheck potassium and eGFR at 4 weeks and after any restart or dose increase. At 4 weeks increase to 20 mg if potassium is 4.8 or below and the eGFR has not fallen by more than 30%; keep 10 mg if potassium is above 4.8 to 5.5; withhold if above 5.5 and restart at 10 mg once 5.0 or below. Never with a second MRA. Contraindicated with strong CYP3A4 inhibitors (for example clarithromycin, itraconazole, ketoconazole, ritonavir) and in Addison's disease; do not use with strong or moderate CYP3A4 inducers (for example rifampicin, carbamazepine, phenytoin, St John's wort, efavirenz); avoid grapefruit juice; check potassium more often with moderate or weak CYP3A4 inhibitors, potassium supplements, trimethoprim or co-trimoxazole (temporary withdrawal may be needed). FIDELIO-DKD and FIGARO-DKD: fewer kidney and cardiovascular events. Finerenone also has a heart-failure indication (symptomatic HFpEF/HFmrEF, NICE TA1182, FINEARTS-HF; see F4).
GLP-1 receptor agonist · after FLOW · KDIGO/ESC sequence, not a NICE pathway
FLOW (Perkovic, NEJM 2024; semaglutide 1 mg weekly; n = 3,533; type 2 diabetes with eGFR 25–75 and albuminuria) cut major kidney disease events by 24% and reduced cardiovascular death. KDIGO 2024 recommends (Rec 3.9.1, 1B) a long-acting GLP-1 receptor agonist when glycaemic targets are not met on metformin and an SGLT2 inhibitor, or when these cannot be used, and advises prioritising agents with documented cardiovascular benefit (Practice Point 3.9.1); it was published before FLOW, whose kidney-outcome results now add direct evidence. ESC/ERA 2026 gives semaglutide 1 mg weekly class I A in type 2 diabetes with CKD at eGFR 25–49 and uACR 10 mg/mmol or more. NICE NG28 (February 2026) reviewed FLOW and did not recommend semaglutide specifically for CKD because it was not cost effective; when more glucose lowering is needed a DPP-4 inhibitor is the first NICE option (1.30.1). A GLP-1 receptor agonist is reached through other NG28 routes: subcutaneous semaglutide up to 1 mg weekly with atherosclerotic cardiovascular disease (1.15.1, 1.27.1), or in people living with obesity (1.29.2). TA875, TA924 and TA1026 are weight-management or triple-therapy-failure appraisals, not the FLOW route.
The sequence in type 2 diabetes with CKD (KDIGO/ESC sequence, not a NICE pathway). Lifestyle and blood pressure with the ACE inhibitor or ARB at maximum tolerated dose → SGLT2 inhibitor → finerenone where albuminuria persists and potassium allows → GLP-1 receptor agonist where glycaemia remains above target (KDIGO 2024, 1B; in NICE terms this applies through atherosclerotic cardiovascular disease or obesity, not on CKD alone). Metformin continues while the eGFR allows (review below 45, stop below 30); a sulfonylurea adds hypoglycaemia risk; pioglitazone causes fluid retention. Agree an individual HbA1c target. NICE NG28 (1.5.7–1.5.9) suggests 48 mmol/mol on lifestyle or a regimen not associated with hypoglycaemia, 53 mmol/mol if a hypoglycaemia-associated medicine is used, and intensifying at 58; relax the target in older, frail or limited-life-expectancy patients. KDIGO 2024 individualises between below 6.5% and below 8.0%.
Checkpoint 4 · Type 2 diabetes, eGFR 48, ACR 35 mg/mmol on maximum ramipril and dapagliflozin, K⁺ 4.6. Next addition?
Finerenone 10 mg daily (eGFR 25–59), with potassium and eGFR at 4 weeks and titration to 20 mg if potassium stays at or below 4.8 mmol/L and the eGFR has not fallen by more than 30%. Not spironolactone, and never both.
The kidney and the heart as one: statin, anaemia, hyperkalaemia, heart failure, referral
The cardiorenal view of the same patient, and the NICE criteria for sending them on.
The statin
NICE NG238 offers atorvastatin 20 mg to adults with CKD for primary or secondary prevention, without a risk score (QRISK3 is not used in CKD); people on renal replacement therapy are outside the guideline. Increase the dose if the lipid target is not met (primary prevention: non-HDL cholesterol down by more than 40%; secondary prevention: LDL cholesterol 2.0 mmol/L or less, or non-HDL cholesterol 2.6 mmol/L or less) and the eGFR is 30 or more; agree higher doses with a renal specialist below 30. Add ezetimibe where needed.
Anaemia and iron
NICE NG203 (1.7.1–1.7.4): consider investigating anaemia when haemoglobin is 110 g/L or less or there are symptoms; if eGFR is above 60 look for other causes, and between 30 and 60 look for other causes with clinical judgement. Assess iron status with percentage hypochromic red cells or reticulocyte haemoglobin content where available; otherwise ferritin and transferrin saturation together, never alone. For people not on haemodialysis consider a trial of oral iron before intravenous iron (intravenous in symptomatic heart failure, see F4). An erythropoiesis-stimulating agent is a specialist decision for anaemia likely to benefit.
Hyperkalaemia
Prognostic therapy is retained, not abandoned: dietary review, stopping potassium-raising drugs, and a potassium binder in CKD G3b–G5 or heart failure (sodium zirconium cyclosilicate TA1148, patiromer TA623) can enable the ACE inhibitor or ARB and the MRA to continue. An SGLT2 inhibitor modestly lowers hyperkalaemia risk. Potassium of 6.0 mmol/L or more is a stop point for the ACE inhibitor or ARB once other potassium-raising drugs are stopped (NG203 1.6.19); ECG changes need urgent assessment.
Heart failure with CKD
The two share RAAS activation, sympathetic excess and fibrosis, and the same drugs treat both. Keep the four pillars (F4) through a stable eGFR of 30–45; titrate the MRA to potassium; use the loop diuretic to congestion, not to a number. The 2026 AHA/ACC/ADA/ASN guideline frames cardiovascular-kidney-metabolic health as one continuum with one plan; the 2026 ESC/ERA guideline brings cardiovascular disease and CKD together in one joint document.
When to refer: NICE NG203
Refer for specialist assessment if any of the following apply (NICE NG203 1.5.5): a five-year kidney failure risk (KFRE) greater than 5% (the four-variable equation: age, sex, eGFR, ACR) · an ACR of 70 mg/mmol or more unless known to be caused by diabetes and already appropriately treated · an ACR over 30 mg/mmol (A3) together with haematuria · a sustained fall in eGFR of 25% or more with a change of eGFR category within 12 months · a sustained fall of 15 mL/min/1.73 m² or more per year · hypertension that remains poorly controlled despite at least four antihypertensive medicines · known or suspected rare or genetic causes of CKD · suspected renal artery stenosis. A stable eGFR does not override a high KFRE; a low KFRE lets most CKD stay in primary care with confidence.
Prepare for kidney failure care early where the KFRE is high: discuss what matters to the patient, avoid vein damage in the non-dominant arm, offer vaccination, and involve the renal team before the eGFR reaches 20.
Checkpoint 5 · eGFR stable at 34 for two years, ACR 28 mg/mmol, five-year KFRE about 10%. Refer?
Yes. A five-year KFRE greater than 5% is a NICE NG203 referral criterion irrespective of a stable eGFR. Many of these patients continue to be managed jointly, but the nephrology plan is made now.
Running it: the searches, the annual review and the CVRM-HF clinic
Where the patients are, what the review contains, and how the kidney work shares a clinic with heart failure and lipids.
Four searches
The annual review bundle
| Element | Detail |
|---|---|
| Measure | eGFR and ACR (frequency by heat-map band); blood pressure, standing where relevant; weight; HbA1c and lipids where indicated; potassium with every ACE inhibitor, ARB or MRA check; haemoglobin (investigate anaemia at 110 g/L or less or if symptomatic, NG203 1.7.1); from G4, calcium, phosphate, PTH and bicarbonate (NG203 1.12.2, 1.12.8) |
| Classify | Update the G and A codes; calculate the KFRE; check the referral criteria |
| Treat | Blood pressure to target; ACE inhibitor or ARB at maximum tolerated dose; SGLT2 inhibitor; finerenone and GLP-1 receptor agonist in type 2 diabetes; atorvastatin 20 mg (not on renal replacement therapy); iron where deficient |
| Protect | Sick-day rules in writing; NSAID caution; dose review by eGFR; vaccination; contrast and surgery planning |
| Record | Which rung of the ladder the patient is on and why the next one was not taken |
The kidney work shares a clinic with heart failure (F4) and lipids (F2): one list, one prescriber, one titration protocol, one set of safety bloods. The cardiovascular disease modern service framework (July 2026) sets the national trajectory; QOF 2026/27 has no CKD monitoring indicators (HF009 and CHOL003 are the related ones), so use NICE NG203 and indicators IND262/IND263 as your standard.
Practice task
Run searches 1 and 2 on your own system this week. Count the uncoded patients and the SGLT2-inhibitor gap, and bring the two numbers to your clinical director or to the Herts Heart Failure Masterclass workshop. Record what you found in the reflection box below; it prints on your certificate.
Checkpoint 6 · The clinical director wants the single search that yields most kidney protection per clinic hour. Which?
The SGLT2-inhibitor gap on the CKD register (plus the uncoded register), with the eligibility and safety columns so the clinic can prescribe from the list.
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New Vision University (UK)
Acumen Focus · CVRM-HF Foundation series · delivered by MD Acumen Ltd
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Acumen Focus F5 · CKD and the cardiorenal axis
including its 10-item knowledge check
Authored by Prof Rajesh Varma · MD Acumen Ltd · mdacumen.com
CPD authorised by Prof Rajesh Varma, Convenor for CPD, New Vision University (UK)
Signed against: NICE NG203 (2021) · KDIGO 2024 · KDIGO 2021 blood pressure in CKD · NICE TA1075 · NICE TA942 · NICE TA877 · NICE TA1182 · NICE TA1148 · NICE TA623 · NICE NG238 · NICE NG28 (February 2026) · ESC/ERA 2026 guidelines for cardiovascular disease and CKD (Damman et al., August 2026) · AHA/ACC/ADA/ASN 2026 CKM guideline · DAPA-CKD (2020) · EMPA-KIDNEY (2023) · FLOW (2024)
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Keep learning
F5 is the kidney half of the cardiorenal pillar in the CVRM-HF Foundation series (F1 cardiometabolic risk · F2 lipids · F3 type 2 diabetes · F4 heart failure · F5 kidney disease · F6 obesity and MASLD). Complete all six for the series certificate (6 CPD); the series counts as recognised prior learning for the Certificate of Advanced Studies in CVRM-HF.
Key sources
Every clinical statement in this module is mapped to a source at each signed review; where no guideline source exists the module says so. Where several licensed agents in a class exist they are presented even-handedly per their NICE technology appraisals.
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