MRCGP AKT · Cardiorenal-Metabolic

CKD in cardiovascular disease: ‘STAMP on CKD’ (ESC/ERA 2026) and NICE NG203

Test every patient with cardiovascular disease for CKD, classify by eGFR and ACR, refer by KFRE, and build the cardiorenal-protective regimen: RAS blockade, SGLT2 inhibitor, statin and, in type 2 diabetes, finerenone.

Reviewed and kept current

Last editorial review: 28 September 2026 · Next scheduled refresh: March 2027.

Start the three questionsAll Cardiorenal-Metabolic units
Start here

Clinical vignette

Begin with the patient. Read the case, weigh the options, then work through the unit.

A 63-year-old man with ischaemic heart disease and type 2 diabetes attends his annual review. He takes ramipril 5 mg, metformin, atorvastatin 80 mg and bisoprolol. His eGFR has been 50–54 mL/min/1.73m² for two years, but a urine albumin:creatinine ratio (ACR) has never been recorded and CKD is not coded.

His ACR is 38 mg/mmol, and 40 mg/mmol on a repeat sample three months later. His blood pressure is 134/80 mmHg and potassium 4.7 mmol/L. His 5-year kidney failure risk (KFRE) is 3%.

Options to weigh

  • Titrate the ACE inhibitor to the maximum tolerated dose (diabetes and ACR 3 mg/mmol or more); check potassium and eGFR before and 1–2 weeks after each increase (NICE NG203).
  • Add an SGLT2 inhibitor (dapagliflozin, NICE TA1075; empagliflozin, NICE TA942).
  • Add finerenone once he is on an optimised ACE inhibitor or ARB and an SGLT2 inhibitor, if CKD is stage 3–4 with ACR persistently ≥3 mg/mmol and eGFR ≥25 (NICE TA877).
  • Refer for specialist assessment if the 5-year KFRE exceeds 5% (NICE NG203); the 2026 ESC/ERA guideline proposes a threshold in the region of 3–5%.
Were you aware?

The 2026 ESC/ERA guideline asks for eGFR and urine ACR in everyone with cardiovascular disease, because eGFR alone misses early CKD with albuminuria. England’s CVD Modern Service Framework (July 2026) expects practices to search for un-coded CKD where ACR is missing. Whether this man is referred also depends on where he is treated: NICE refers at a 5-year KFRE above 5%, while the ESC proposes a threshold in the region of 3–5%.

The Golden Triangle

Every condition has a Golden Triangle: what we know, what the evidence says, and what actually happens. Each apex is rated Red, Amber or Green. The Equinox, at the centre, is where all three meet in equal measure; the arrow shows the apex that must be drawn in to reach it.

Golden Triangle: Chronic kidney diseaseGolden Triangle for Chronic kidney disease (UK (NHS England)). Knowledge: Green; Evidence: Green; Real-world: Red. The triangle is white because it has not reached the Equinox. Real-world has two arrows toward the Equinox.Knowledge · GreenEvidenceGreenReal-worldRed

Chronic kidney disease UK (NHS England)

ApexRatingWhy
KnowledgeGreenClassified by eGFR (G1–G5) and ACR (A1–A3), confirmed over 3 months; the KFRE gives 5-year kidney failure risk.
EvidenceGreenRAS inhibitor, SGLT2 inhibitor and statin; finerenone in T2D (ESC 2026, I A; NICE TA1075, TA942, TA877).
Real-worldRedWomen with CKD get an SGLT2 inhibitor less often than men (26.8% v 40.0%, Mar 2026). Kidney failure is about twice as common in deprived areas.

Pull toward the Equinox — Real-world. Add urine ACR to every CVD, hypertension and diabetes review; search for un-coded CKD; refer at a 5-year KFRE above 5%; optimise ACEi or ARB, then add an SGLT2i.

Sources for this triangle
  1. NICE NG203. Chronic kidney disease: assessment and management. (Published 25 August 2021; last updated 24 November 2021)
  2. Damman K, et al. 2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease. Eur Heart J 2026. (Published 28 August 2026)
  3. NICE TA1075. Dapagliflozin for treating chronic kidney disease. (Published 2 July 2025)
  4. NICE TA942. Empagliflozin for treating chronic kidney disease. (Published 20 December 2023)
  5. NICE TA877. Finerenone for treating chronic kidney disease in type 2 diabetes. (Published 23 March 2023)
  6. Department of Health and Social Care and NHS England. Cardiovascular disease modern service framework. (7 July 2026)
  7. CVDPREVENT data explorer and API (NHS Benchmarking Network / OHID). (Indicators to March 2026 (accessed 7 October 2026))
  8. UK Kidney Association. Socioeconomic disparities in kidney failure and access to transplantation (UK Renal Registry). (2023 (data 2014–2020))
Golden Triangle: Type 2 diabetesGolden Triangle for Type 2 diabetes (UK (NHS England)). Knowledge: Green; Evidence: Green; Real-world: Amber. The triangle is white because it has not reached the Equinox. Real-world has one arrow toward the Equinox.Knowledge · GreenEvidenceGreenReal-worldAmber

Type 2 diabetes UK (NHS England)

ApexRatingWhy
KnowledgeGreenRaised blood glucose, including non-diabetic hyperglycaemia, is an MSF risk factor; HbA1c is part of case-finding.
EvidenceGreenWith CKD: SGLT2 inhibitor (ESC 2026, I A; NICE TA1075, TA942), then finerenone on optimised therapy (TA877).
Real-worldAmberAll 8 annual care processes were done for 58.2% of people with type 2 diabetes in 2024-25; integrated care boards ranged from 38.6% to 73.5%.

Pull toward the Equinox — Real-world. Record eGFR and ACR at every review; sequence ACEi or ARB, SGLT2 inhibitor, statin and finerenone; give sick-day guidance; audit SGLT2-inhibitor uptake.

Sources for this triangle
  1. Department of Health and Social Care and NHS England. Cardiovascular disease modern service framework. (7 July 2026)
  2. Damman K, et al. 2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease. Eur Heart J 2026. (Published 28 August 2026)
  3. NICE TA1075. Dapagliflozin for treating chronic kidney disease. (Published 2 July 2025)
  4. NICE TA942. Empagliflozin for treating chronic kidney disease. (Published 20 December 2023)
  5. NICE TA877. Finerenone for treating chronic kidney disease in type 2 diabetes. (Published 23 March 2023)
  6. NICE NG203. Chronic kidney disease: assessment and management. (Published 25 August 2021; last updated 24 November 2021)
  7. NICE Clinical Knowledge Summaries. Diabetes – type 2: management in adults (sick-day rules). (Last revised July 2026)
  8. NHS England. National Diabetes Audit, Report 1: care processes and treatment targets, 2024-25. (Published 12 February 2026)

Reflect

Given the gap, what is your duty as the doctor — and how would you inform the patient of their access to care when the referral threshold differs between guidelines?

Unit overview

What this unit covers

Pocket-sized and self-contained: three AKT-style questions, the answers explained, an expanded discussion with hyperlinked guidance, a decision algorithm and a certificate.

Unit code
MDA-AKT-CK-REN-01
AKT domain
Clinical knowledge≈80% (128 of 160 items)
Study time
25 minutesCPD, self-certified
Pass mark
2 of 3unlocks your certificate
RCGP Topic Guide: Renal and urologyRCGP Topic Guide: Cardiovascular healthRCGP Topic Guide: Metabolic problems and endocrinologyRCGP · Applied Knowledge Test

By the end of this unit you will be able to

✓Describe the five steps of ‘STAMP on CKD’ from the first ESC/ERA CVD–CKD guideline (August 2026).
✓Classify CKD by GFR (G1–G5) and albuminuria (A1–A3) categories.
✓Apply NICE NG203 referral criteria, including the 5-year kidney failure risk equation (KFRE).
✓Sequence ACE inhibitor/ARB, SGLT2 inhibitor, statin and finerenone according to NICE.
The unit

Five steps, in order

Answer first, then learn. Each section unlocks as you progress, and your progress is saved in this browser.

1Three single best answer questions

Commit to an answer for all three single best answer questions, then submit. Sections 2–4 open on submission; your certificate opens at 2/3 or better.

Question 1 of 3

A 63-year-old man attends his annual review for ischaemic heart disease. He has no known kidney disease.

Which tests does the 2026 ESC/ERA guideline recommend (Class I) to screen him for chronic kidney disease?

Question 2 of 3

A 64-year-old woman with type 2 diabetes has CKD with eGFR 38 mL/min/1.73m² and ACR 45 mg/mmol, stable over the past year. Her 5-year kidney failure risk (KFRE) is 7%. Her blood pressure is controlled on two drugs.

What is the most appropriate action according to NICE?

Question 3 of 3

A 58-year-old man with type 2 diabetes and CKD (eGFR 52 mL/min/1.73m², ACR 40 mg/mmol) is taking ramipril 10 mg daily, metformin and atorvastatin 20 mg. His blood pressure is 128/78 mmHg and potassium 4.8 mmol/L.

What is the most appropriate next step to reduce his kidney and cardiovascular risk?

2Answers explained

Question 1

Correct answer C. Creatinine-based eGFR and a spot urine albumin:creatinine ratio

The ‘S’ of STAMP on CKD is Screen: every patient with cardiovascular disease should be tested with creatinine-based eGFR and a spot (ideally early-morning) urine ACR, classified by GFR and albuminuria categories, and confirmed over three months.

eGFR alone misses early CKD with albuminuria, which carries substantial cardiovascular and renal risk. Dipstick testing is not a substitute for ACR. NICE NG203 similarly uses eGFR plus ACR to diagnose and stage CKD.

Question 2

Correct answer A. Refer for specialist assessment because her 5-year KFRE exceeds 5%

NICE NG203 recommends referral for specialist assessment when the 5-year risk of kidney failure (KFRE) is greater than 5%. Other referral triggers include:

  • ACR ≥70 mg/mmol, unless it is known to be caused by diabetes and is already appropriately treated;
  • ACR ≥30 mg/mmol with haematuria;
  • a sustained fall in eGFR of 25% or more with a change in GFR category, or of 15 mL/min/1.73m² or more within 12 months;
  • hypertension that remains poorly controlled despite four or more antihypertensives;
  • known or suspected rare or genetic causes of CKD, or suspected renal artery stenosis.

NICE replaced a fixed eGFR <30 trigger with risk-based referral using the KFRE (option C is the trap).

Question 3

Correct answer E. Add an SGLT2 inhibitor

With type 2 diabetes, CKD and an optimised ACE inhibitor, NICE recommends adding an SGLT2 inhibitor (dapagliflozin — TA1075; empagliflozin — TA942; see also NG203 and NG28). This is also core ESC/ERA 2026 therapy.

  • Finerenone (NICE TA877) is an add-on to optimised ACEi/ARB and SGLT2 inhibitor in adults with T2D, stage 3–4 CKD and persistent ACR ≥3 mg/mmol, with eGFR ≥25.
  • Dual RAS blockade (ACEi + ARB) is not recommended — hyperkalaemia and AKI.
  • An eGFR fall of up to 25% (or creatinine rise up to 30%) after starting an ACEi is acceptable; eGFR <60 alone is not a reason to stop.
3Expanded discussion, worked examples & guidance

1. ‘STAMP on CKD’ — the 2026 ESC/ERA framework

StepMeaningIn primary care
ScreeneGFR + urine ACR in everyone with CVDAdd ACR to every CVD annual review
Triage and stage CKDConfirm CKD (eGFR below 60 or ACR 3 mg/mmol or more, persistent for at least 3 months); stage by G and A categories; consider the causeCode CKD with its G and A category
Address CKD riskCalculate individual risk: KFRE in G3–G5; SCORE2 or SCORE2-OP with the CKD add-on. Treat: RAS inhibitor, SGLT2 inhibitor, statin-based therapy, systolic target 120–129 mmHg if tolerated (eGFR ≥30); finerenone and a GLP-1 RA (semaglutide) in T2D with CKDUse KFRE to decide on referral; optimise the regimen; sick-day guidance
Modify approach to CVD managementAdapt CVD treatment to kidney function (e.g. DOAC rather than VKA down to eGFR 15 in AF)Dose-adjust by CrCl or eGFR; review nephrotoxins
Plan health servicesCollaborate across specialties, communicate with patients, and do not delay CVD treatment because of CKDAligns with the UK CVKM approach

2. Classification (KDIGO, used by NICE)

GFR categoryeGFR
G1≥90 (with other markers of kidney damage)
G260–89 (with other markers)
G3a45–59
G3b30–44
G415–29
G5<15

Albuminuria: A1 ACR <3 mg/mmol; A2 3–30; A3 >30. Risk rises with both — a patient with G2 A3 may be at higher risk than one with G3a A1. Confirm CKD with abnormal results persisting for more than 3 months.

3. Treatment in UK practice (NICE)

  • ACE inhibitor or ARB (titrated to the maximum tolerated dose): offer if diabetes and ACR >3 mg/mmol; if hypertension and ACR >30 mg/mmol; and to anyone with ACR ≥70 mg/mmol. Check potassium and eGFR before and 1–2 weeks after starting or increasing the dose.
  • SGLT2 inhibitor: with T2D and CKD (NG28/NG203); and, per TA1075 and TA942, for adults with CKD on optimised ACEi/ARB who have eGFR 20 to <45, or eGFR 45–90 with ACR ≥22.6 mg/mmol or type 2 diabetes.
  • Statin: atorvastatin 20 mg for primary prevention in CKD (NG238). Increase if non-HDL cholesterol falls by less than 40%, with specialist advice if eGFR <30.
  • Finerenone (TA877): T2D, CKD stage 3–4 with ACR ≥3 mg/mmol, eGFR ≥25, on optimised ACEi/ARB and SGLT2 inhibitor.
  • Blood pressure (NG203/NG136): clinic target below 140/90 mmHg; if ACR ≥70 mg/mmol, aim for systolic 120–129 and diastolic below 80.
UK vs ESCThe ESC/ERA 2026 guideline proposes a KFRE referral threshold in the region of 3–5% and targets systolic BP of 120–129 mmHg if tolerated (eGFR ≥30). NICE refers at a 5-year KFRE above 5%. In the AKT, use NICE.

4. Worked example — KFRE and category

Two patients, same eGFR

Patient A: 80 years, eGFR 35, ACR 2 → G3b A1; 5-year KFRE 1%. Patient B: 52 years, eGFR 35, ACR 90 → G3b A3; 5-year KFRE 18%.

  1. A: manage in primary care — BP, statin, review medicines, monitor.
  2. B: refer (KFRE >5% and ACR ≥70); start or optimise ACEi/ARB and SGLT2 inhibitor now.

Answer. Same eGFR, very different risk. Albuminuria and age drive the KFRE — this is population vs individual risk in practice (Statistics Unit 5).

5. Safety

Sick-day guidance: temporarily stop ACEi/ARB, diuretics, MRAs, SGLT2 inhibitors, metformin and NSAIDs during dehydrating illness (vomiting, diarrhoea, fever) and restart 24–48 hours after eating and drinking normally. Avoid NSAIDs in CKD. Dose-adjust renally excreted drugs (DOACs, gabapentinoids, nitrofurantoin — avoid if eGFR <45 except short courses under specific conditions — and metformin: review at eGFR <45, stop at <30).

High-yield AKT facts
  • CKD = eGFR <60 or markers of damage (e.g. ACR ≥3) for more than 3 months.
  • ACR, not PCR, for diabetes and routine CKD testing.
  • After starting an ACEi: a fall in eGFR of less than 25% (or a rise in creatinine of less than 30%) is acceptable — do not stop.
  • Refer at 5-year KFRE >5% (NICE).

References and further reading

Guidance checked at the last editorial review (28 September 2026). Always use the current version.

  1. 2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease (doi 10.1093/eurheartj/ehag098)
  2. ESC press release — all patients with heart disease to be tested for kidney disease (Aug 2026)
  3. NICE NG203 — Chronic kidney disease: assessment and management
  4. NICE TA1075 — Dapagliflozin for treating chronic kidney disease
  5. NICE TA942 — Empagliflozin for treating chronic kidney disease
  6. NICE TA877 — Finerenone for treating CKD in type 2 diabetes
  7. Kidney Failure Risk Equation (UK Kidney Association resources)
  8. NICE CKS — Chronic kidney disease
  9. DHSC/NHS England — Cardiovascular disease modern service framework (July 2026)
4Decision algorithm

CKD in a patient with cardiovascular disease

1

Start

Patient with CVD, hypertension or diabetes at annual review.

2

Action

Screen: creatinine-based eGFR + early-morning urine ACR.

3

Decision

eGFR < 60 or ACR ≥ 3 mg/mmol, persisting over 3 months?

YesCKD: classify G and A categories and calculate the 5-year KFRE (G3–G5).
NoNo CKD: re-test annually if at risk.
4

Decision

Does the patient meet NICE referral criteria (KFRE > 5%, ACR ≥ 70, ACR ≥ 30 with haematuria, rapid eGFR decline, resistant hypertension, suspected rare cause)?

YesRefer for nephrology assessment and continue optimising treatment meanwhile.
NoManage in primary care.
5

Action

Address risk: ACEi/ARB to the maximum tolerated dose (by ACR thresholds) → SGLT2 inhibitor → atorvastatin 20 mg → finerenone if T2D and criteria met.

6

Outcome

Modify CVD care for kidney function (DOAC dosing, avoid NSAIDs), give sick-day guidance, and monitor eGFR/ACR at a frequency set by the KDIGO heat map.

Revision summary; apply clinical judgement and local pathways.

5Certificate of completion

You have met the pass mark. Enter your details to issue your personalised certificate of completion, then save it as a PDF for your appraisal or revalidation portfolio.

Where next?

← Heart failure in 2026: diagnosis, NT-proBNP and foundational therapy (ESC 2026 vs NICE)The CVD Modern Service Framework (July 2026) and cardiovascular-kidney-metabolic prevention →🎓 DCRM Certificate of Advanced Studies✉️ enquiry@mdacumen.com
© 2026 MD Acumen Ltd · MD Acumen School of Postgraduate Medicine · Registered in England and Wales · 16538952
MRCGP AKT · CAS Programmes · For institutions · Legal & regulatory · enquiry@mdacumen.com
Educational content for healthcare professionals; apply clinical judgement and current local guidance. MRCGP is a registered trademark of the Royal College of General Practitioners. These units are independent, curriculum-aligned revision resources and are not endorsed by the RCGP.