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Upon completion of the chapter, the reader will be able to:

  1. List the risk factors for development and progression of chronic kidney disease (CKD).

  2. Explain the mechanisms associated with progression of CKD.

  3. Outline the desired outcomes for treatment of CKD.

  4. Develop a therapeutic approach to slow progression of CKD, including lifestyle modifications and pharmacologic therapies.

  5. Identify specific consequences associated with CKD.

  6. Design an appropriate therapeutic approach for specific consequences associated with CKD.

  7. Recommend an appropriate monitoring plan to assess the effectiveness of pharmacotherapy for CKD and specific consequences.

  8. Educate patients with CKD about the disease state, the specific consequences, lifestyle modifications, and pharmacologic therapies used for treatment of CKD.




The kidney is made up of approximately 2 million nephrons that are responsible for filtering, reabsorbing, and excreting solutes and water. The kidney has three primary functions: excretory (excrete fluid, electrolytes, and solutes); metabolic (metabolize vitamin D and some drugs, such as insulin and some β-lactams); and endocrine (produce erythropoietin). As the number of functioning nephrons declines, the primary functions of the kidney that are affected include:


  • Production and secretion of erythropoietin

  • Activation of vitamin D

  • Regulation of fluid and electrolyte balance

  • Regulation of acid–base balance


Chronic kidney disease (CKD) is defined as abnormalities in the structure or function of the kidney, present for 3 months or more, with implications for health.1 Markers of structural abnormalities include albuminuria (30 mg/24 hours or more or an albumin: creatinine ratio (ACR) of more than 30 mg/g [or 3.5 mg/mmol for female and 2.5 mg/mmol for male but varies between different guidelines and location]); hematuria or casts in urine sediment; electrolyte and other abnormalities caused by renal tubular disorders; abnormalities detected by histology or imaging; or history of kidney transplantation. Functional abnormalities are indicated by a decline in glomerular filtration rate (GFR) less than 60 mL/min/1.73m2 (0.58 mL/s/m2). Generally, CKD is a progressive decline in kidney function (number of functioning nephrons) that occurs over several months to years. A rapid decline in kidney function over days to weeks is known as acute kidney injury (AKI), which is discussed in Chapter 25. Because the decline in kidney function in CKD is often irreversible, treatment of CKD is aimed at slowing the progression to end-stage kidney disease (ESKD).




KEY CONCEPT The Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group developed a classification system for CKD.1 The staging system defines the stages of CKD based on cause, GFR category and albumin category, as outlined in Tables 26–1 and 26–2. The previous classification system for CKD was developed by the National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative (KDOQI), which used only the GFR to determine the stage of CKD.3 Most of the literature and guidelines refer to the KDOQI staging system. Table 26–1...

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