Managing Chronic Kidney Disease

Introduction

Managing chronic kidney disease (CKD) is not a single action but an ongoing process. The goals are to slow the loss of kidney function, reduce cardiovascular risk, manage complications, and — for those with advanced disease — prepare for what may come next.

Most of what matters in CKD management is consistent and unglamorous: knowing your numbers, controlling blood pressure, taking prescribed medicines, and attending regular follow-up. These steps make a meaningful difference to outcomes.

This guide covers what to monitor, what to do, and what to be aware of at each stage.

Key Points

Blood pressure control is the most important modifiable factor for slowing CKD progression
Diabetes management is central for people with diabetic kidney disease
Some medicines protect kidneys; others can harm them — a regular medication review matters
Diet advice in CKD should be personalised, not self-directed
All stages of CKD carry increased cardiovascular risk — this is managed alongside kidney protection
Planning for advanced CKD begins well before dialysis is needed
Seek urgent help for sudden worsening of symptoms or rapid changes in kidney function

What CKD Management Is Trying to Achieve

CKD cannot usually be reversed. The aim of treatment is to:

Slow progression — reduce the rate at which kidney function declines
Reduce cardiovascular risk — CKD raises the risk of heart attack and stroke; managing this is as important as managing the kidneys themselves
Prevent and manage complications — anaemia, bone disease, fluid overload, and potassium changes all occur more often as kidney function declines
Maintain quality of life — managing symptoms, supporting nutrition, and addressing fatigue and other impacts
Plan ahead — for people with progressive disease, timely planning for dialysis, transplant, or conservative management allows more informed and dignified choices

Know Your Kidney Numbers

Understanding a few key results helps make sense of medical appointments and treatment decisions.

eGFR

eGFR (estimated glomerular filtration rate) estimates how much blood the kidneys filter per minute. It is calculated from a blood test for creatinine, adjusted for age and sex. A lower number indicates reduced kidney function.

eGFR is used to stage CKD (from Stage 1 to Stage 5) and to guide monitoring frequency and treatment decisions. Trends over time matter as much as a single reading — an eGFR that is declining year-on-year is more concerning than a stable reading at the same level.

Urine ACR (Albumin-to-Creatinine Ratio)

Albumin is a protein that should stay in the blood. When kidneys are damaged, albumin leaks into the urine. The ACR measures this leakage. Elevated ACR is an important indicator of kidney damage and an independent predictor of both CKD progression and cardiovascular risk.

Blood Pressure

Blood pressure should be monitored regularly in CKD. High blood pressure is both a cause and a consequence of kidney disease. Target blood pressure in CKD is generally lower than population targets — a clinician will advise on the right goal for an individual.

Potassium

The kidneys regulate potassium levels. In CKD, potassium can build up (hyperkalaemia), causing muscle weakness and potentially dangerous heart rhythm changes. Potassium is checked regularly; diet and, where needed, medicines help manage it.

Haemoglobin

The kidneys produce erythropoietin, which stimulates red blood cell production. Reduced kidney function often leads to anaemia (low haemoglobin). Regular checks allow this to be identified and treated.

Bone and Mineral Tests

The kidneys regulate calcium, phosphate, and vitamin D. As CKD progresses, these become dysregulated — affecting bone strength, parathyroid hormone levels, and blood vessel calcification. Blood tests for calcium, phosphate, parathyroid hormone, and vitamin D form part of monitoring at moderate and advanced stages.

Blood Pressure and CKD

Controlling blood pressure is the most important intervention for slowing CKD progression and reducing cardiovascular risk.

High blood pressure damages the kidney’s filtration units (glomeruli). As the kidneys become damaged, they are less able to regulate blood pressure — creating a cycle that drives deterioration of both systems.

What you can do:

Know your blood pressure target (your clinician will advise — it is often lower than general population targets in CKD, particularly with significant albuminuria)
Check blood pressure regularly — at home if advised, and at clinical reviews
Take prescribed blood pressure medicines consistently
Reduce salt intake
Maintain a healthy weight
Limit alcohol
Exercise regularly

ACE inhibitors (such as ramipril and perindopril) and ARBs (angiotensin receptor blockers, such as irbesartan and candesartan) are commonly used in CKD. Beyond their blood pressure-lowering effects, they reduce protein leakage from the kidneys and have direct kidney-protective properties. They require regular monitoring of kidney function and potassium.

See: High Blood Pressure (Hypertension)

Diabetes and CKD

For people with both diabetes and CKD, managing blood glucose is a core part of kidney protection. High blood glucose damages the small blood vessels supplying the kidneys — sustained control significantly slows this damage.

Key points:

HbA1c targets in CKD may need to be individualised — very tight control may carry greater hypoglycaemia risk, particularly in older adults or those with advanced CKD
Some diabetes medicines require dose adjustment or are not suitable at lower eGFR levels — a diabetes team or GP can review
Blood glucose monitoring and regular diabetes reviews remain important even when CKD is also being managed

See: Type 2 Diabetes | Diabetes Hub

Kidney-Protective Medicines

Several medicine classes have evidence for slowing kidney disease progression or reducing cardiovascular risk in CKD. These are not suitable for everyone — suitability depends on eGFR, ACR, other conditions, and individual clinical factors. A clinician will determine whether any of these are appropriate.

ACE inhibitors and ARBs Used for blood pressure control, they also reduce albuminuria and have kidney-protective effects. They require monitoring of kidney function and potassium. Not suitable in all circumstances.

SGLT2 inhibitors Originally developed as diabetes medicines, SGLT2 inhibitors (such as empagliflozin and dapagliflozin) have shown kidney-protective and cardiovascular-protective effects in clinical trials, including in people without diabetes. They are now used for some people with CKD and significant albuminuria, or CKD alongside heart failure or type 2 diabetes. However, suitability depends on kidney function level, diagnosis, other medicines, and individual factors — not everyone with CKD will be prescribed them.

Statins and cardiovascular risk reduction Because CKD significantly raises cardiovascular risk, statin therapy for cholesterol management is often appropriate. A clinician will assess overall cardiovascular risk to decide.

Other medicines Additional medicines may be used to manage specific complications — for anaemia (such as iron or erythropoiesis-stimulating agents), bone mineral disease, or high potassium. These are prescribed based on blood results and clinical assessment.

Medication Safety

Kidney disease changes how many medicines behave in the body. For a broader overview covering polypharmacy, discharge transitions, blood thinners, and supplements, see Medication Safety: How to Avoid Common Medicine Problems.

NSAIDs (Anti-inflammatory Medicines)

Ibuprofen, naproxen, and other NSAIDs reduce blood flow to the kidneys. Regular use can worsen kidney function and accelerate CKD progression. People with CKD are generally advised to avoid them, or use them only briefly and under clinical guidance. Always ask a pharmacist or clinician before using anti-inflammatory medicines regularly.

Contrast Dyes (for Scans)

Iodinated contrast agents used in CT scans and some other imaging procedures can affect kidney function in people with CKD, particularly at lower eGFR levels. Always inform the radiology or imaging team of your kidney function before any procedure involving contrast. Your clinician can advise whether contrast is safe and whether any precautions are needed.

Supplements and Herbal Products

Many complementary medicines, supplements, and herbal preparations are processed by the kidneys or can interact with kidney function or medicines. Always disclose all supplements and herbal products to your clinician or pharmacist.

Sick Day Rules

Acute illness — particularly with vomiting, diarrhoea, fever, or reduced fluid intake — can cause rapid deterioration in kidney function. Some medicines (particularly blood pressure medicines, diuretics, and certain diabetes medicines) may need to be temporarily paused during acute illness to protect the kidneys. Your clinical team can advise on a personalised sick day plan. Do not stop regular medicines without guidance, but seek advice promptly when you are acutely unwell.

Diet and Lifestyle

Salt Reduction

Reducing salt intake helps control blood pressure — one of the most important dietary changes in CKD. This includes reducing added salt and monitoring high-sodium foods such as processed meats, canned goods, and salty snacks.

Protein Intake

Some evidence suggests that very high protein intake may strain the kidneys. However, protein restriction in CKD can increase the risk of malnutrition. Protein advice in CKD should be personalised by a dietitian based on kidney stage, nutritional status, and other conditions.

Potassium and Phosphate

In more advanced CKD, blood potassium and phosphate may rise to levels that need dietary management. However, unnecessarily restricting these nutrients without evidence of raised levels is not recommended. Blood test results, not general advice, should drive dietary changes — a kidney dietitian can guide this.

Smoking Cessation

Smoking damages blood vessels, raises blood pressure, accelerates kidney disease progression, and substantially increases cardiovascular risk. Stopping smoking is one of the most beneficial changes a person with CKD can make.

Physical Activity

Regular physical activity helps control blood pressure, blood glucose, and weight — all of which are important in CKD management. Activity should be matched to fitness level and other conditions. Speak to your clinical team about what level and type of exercise is appropriate.

Weight and Metabolic Health

Excess weight contributes to high blood pressure and insulin resistance, both of which drive CKD progression. For people who are overweight or obese, weight management is part of kidney protection.

Monitoring and Follow-up

How Often?

Monitoring frequency in CKD depends on stage, albuminuria level, rate of change, and other conditions. In general:

More frequent monitoring is needed at higher stages and with greater albuminuria
People with stable, mild CKD may need annual checks
Those with progressive, advanced, or complicated CKD are monitored more frequently — sometimes every 3–6 months or more often

Who Is Involved?

GP or primary care clinician — coordinates CKD monitoring, prescribes and reviews medicines, manages blood pressure and diabetes, organises referral when needed.

Nephrologist (kidney specialist) — involved at moderate-to-advanced stages, rapid progression, uncertain diagnosis, or complex management needs.

Pharmacist — medicine review, dose adjustment in CKD, identification of kidney-harming medicines, sick day advice.

Kidney dietitian — dietary assessment and personalised advice on protein, potassium, phosphate, fluid, and salt.

Diabetes care team — if diabetes is present, coordination of blood glucose management and medicine review in CKD.

Managing Complications

Anaemia

When the kidneys produce insufficient erythropoietin, red blood cell production falls. Anaemia in CKD causes fatigue, breathlessness, and reduced exercise tolerance. It is assessed through blood tests and managed depending on cause and severity — iron deficiency is addressed first; erythropoiesis-stimulating agents may be used for some people with more severe anaemia.

Bone and Mineral Disease

Dysregulated calcium, phosphate, vitamin D, and parathyroid hormone in CKD weakens bones and increases cardiovascular risk from calcium deposits in blood vessels. Management may include dietary phosphate modification, phosphate binders, vitamin D supplementation, and medicines affecting parathyroid hormone.

Fluid Retention

Advanced CKD reduces the kidneys’ ability to excrete fluid. Swelling of legs and ankles, rising blood pressure, and breathlessness may develop. Fluid and salt intake may need restriction; diuretics may be used.

Itching (Pruritus)

Uraemic pruritus — itching associated with kidney failure — affects some people with advanced CKD. It can significantly affect quality of life. Management options are available; let your clinical team know if this is a problem.

Fatigue

Fatigue is common in CKD and multifactorial — contributed to by anaemia, sleep disturbance, metabolic changes, and medication effects. Addressing reversible causes (particularly anaemia) is the first step. A clinical team can help assess what is contributing.

Cardiovascular Risk

CKD is an independent cardiovascular risk factor. Active management of blood pressure, cholesterol, and diabetes, alongside not smoking and regular physical activity, forms the basis of cardiovascular risk reduction in CKD. Some guidelines recommend treating CKD as a high cardiovascular risk category.

See: Cardiovascular Risk Assessment

Preparing for Advanced CKD

For people with progressive disease, preparation for advanced stages is more helpful when started early.

Dialysis Education

Understanding dialysis options — haemodialysis and peritoneal dialysis — helps people make informed choices about which approach might suit their lifestyle and circumstances. Education is typically offered through kidney specialist services.

Transplant Assessment

For eligible people, transplant assessment begins when kidney function is falling toward Stage 4–5. Assessment considers general health, cardiovascular status, infection screening, and surgical suitability. Being listed for a transplant early, where eligible, maximises the chance of receiving one.

Conservative Kidney Management

For some people — particularly older adults with multiple conditions and reduced life expectancy — conservative kidney management (supportive care without dialysis) may be the most appropriate choice. This approach focuses on symptom management, quality of life, and maintaining dignity.

Advance Care Planning

Conversations about future treatment preferences, resuscitation wishes, and priorities of care are an important part of managing advanced CKD. These conversations are best held before a crisis, when the person with CKD can participate fully and make considered decisions.

Palliative and Supportive Care

Palliative care is not only for the final days of life. It focuses on managing symptoms, supporting quality of life, and addressing psychological and social needs — and can be integrated with kidney treatment at any advanced stage.

See: Palliative Care — Guide Hub

When to Seek Urgent Help

Seek emergency care for:

Severe breathlessness, particularly at rest
Chest pain
Confusion or altered consciousness
Sudden fainting or collapse
Severe and rapidly worsening swelling
Very low urine output or no urine output
Signs of severe infection (high fever, shaking, rapid deterioration)
Rapidly worsening symptoms that are unusual for you

If you have CKD and become acutely unwell — with vomiting, diarrhoea, or high fever — seek medical advice early. Acute kidney injury (AKI) can develop rapidly in people with CKD during illness, particularly if fluid intake is reduced.

FAQ

What is the main goal of CKD management? To slow the loss of kidney function, reduce cardiovascular risk, prevent and manage complications, and plan ahead for any progression. Consistent monitoring and treatment make a meaningful difference to outcomes.

Why is blood pressure important in CKD? High blood pressure accelerates kidney damage. Kidney disease raises blood pressure. Controlling blood pressure well is the single most impactful intervention for slowing CKD in most people.

Do people with CKD need a special diet? Some people need dietary adjustments, but the right changes depend on blood results, kidney stage, and other conditions. A kidney dietitian can provide personalised advice. Unsupervised restriction of potassium or protein without evidence of need is not recommended.

Should people with CKD avoid anti-inflammatory medicines? NSAIDs (such as ibuprofen and naproxen) reduce kidney blood flow and should generally be avoided in CKD. Always check with a clinician or pharmacist before using anti-inflammatory medicines if you have known kidney disease.

When is dialysis discussed? Planning begins when kidney function has declined significantly and progression appears likely — typically at Stage 4 CKD or earlier if decline is rapid. The aim is to have a plan in place before dialysis becomes urgent.