Chronic Kidney Disease (CKD): Stages, Management, and Nursing Care

Chronic kidney disease (CKD) is a progressive, irreversible loss of kidney function that nurses encounter across nearly every care setting. This guide reviews how CKD is staged, why it causes the complications it does, and the priority assessments, medications, and patient teaching points you need for safe practice and exam success.

What Is Chronic Kidney Disease?

• CKD is the progressive, irreversible loss of kidney function over months to years.
• Defined as a glomerular filtration rate (GFR) below 60 mL/min for 3 months or more.
• CKD increases risk of cardiovascular disease, infection, and death.

Stages of CKD

Mnemonic: "90, 60, 45, 30, 15 — the lower the number, the worse the kidney."

Common Causes

• Diabetes mellitus — the leading cause of CKD worldwide.
• Hypertension — the second most common cause.
• Glomerulonephritis and polycystic kidney disease.

Pathophysiology

• Progressive nephron loss leads to hyperfiltration in remaining nephrons.
• Uremic toxins accumulate as GFR declines.
• Erythropoietin production decreases, causing anemia.
• Calcium and phosphorus balance is disrupted, causing bone disease (renal osteodystrophy).

Clinical Presentation

• Fatigue, weakness, and malaise from anemia and toxin accumulation.
• Nausea, vomiting, anorexia, and metallic taste as uremia worsens.
• Pruritus from phosphorus accumulation and urea crystals (uremic frost).
• Fluid overload: edema, hypertension, pulmonary congestion.
• Hyperkalemia: muscle weakness and cardiac arrhythmias.
• Metabolic acidosis: Kussmaul breathing and altered mental status.

Diagnostic Tests

Management Goals

• Slow progression of kidney disease.
• Treat underlying causes — tight glucose and blood pressure control.
• Manage complications: anemia, bone disease, electrolyte imbalances.

Blood Pressure Management

• Target BP <130/80 mmHg.
• ACE inhibitors or ARBs are first-line for patients with albuminuria (renal protective).
• Monitor potassium and creatinine after starting or increasing the dose (risk of hyperkalemia).

Diabetes Management

• Tight glucose control slows progression of diabetic nephropathy.
• SGLT2 inhibitors slow CKD progression and reduce cardiovascular risk.
• Metformin is safe in early CKD but requires dose adjustment or discontinuation as GFR drops.

Electrolyte Management

• Hyperkalemia: restrict dietary potassium — avoid bananas, oranges, potatoes.
• Avoid NSAIDs, ACE inhibitors, and ARBs if hyperkalemia is severe.
• Hyperphosphatemia: restrict dietary phosphorus — avoid dairy and nuts.
• Phosphate binders (e.g., calcium acetate, sevelamer) MUST be taken with meals.
• Sodium bicarbonate treats metabolic acidosis and slows progression.

Anemia Management

• Anemia results from decreased erythropoietin production.
• Target hemoglobin: 10–11 g/dL (not the normal 14–16 g/dL).
• Erythropoiesis-stimulating agents (ESAs) such as epoetin alfa are given subcutaneously.
• Do not exceed target Hgb due to thromboembolic risk (stroke/MI).

Bone Disease Management

• Treat hyperphosphatemia with dietary restriction and phosphate binders.
• Vitamin D analogs (e.g., calcitriol) suppress parathyroid hormone (PTH).
• Monitor calcium, phosphorus, and PTH levels regularly.

Renal Replacement Therapy (RRT)

Indications to Start Dialysis

• Uremic symptoms: nausea, vomiting, fatigue, confusion.
• Fluid overload refractory to diuretics.
• Severe hyperkalemia not responsive to medical management.
• GFR <15 with symptoms or complications.

Options

• Hemodialysis: 3 times per week; requires AV fistula or graft.
• Peritoneal dialysis: performed daily at home; risk of peritonitis (cloudy outflow).
• Kidney transplantation: the optimal treatment for eligible patients.

Nursing Assessment

• Monitor blood pressure, weight, and fluid status daily.
• Assess for fluid overload: edema, crackles, JVD, dyspnea.
• Monitor serum creatinine, GFR, electrolytes, and hemoglobin trends.
• Assess for hyperkalemia: muscle weakness, peaked T waves on ECG.

Nursing Interventions

• Restrict fluids, sodium, potassium, and phosphorus as ordered.
• Administer antihypertensives, phosphate binders, and ESAs.
• Skin care for pruritus: avoid scratching, use cool compresses/lotions.
• Monitor vascular access sites (bruit and thrill) for dialysis.

Patient Teaching

• Take medications exactly as prescribed.
• Follow dietary restrictions: low sodium, low potassium, low phosphorus.
• Monitor daily weight; report increases >2–3 lbs in a day.
• Report signs of fluid overload or hyperkalemia.
• Avoid NSAIDs (ibuprofen, naproxen) and other nephrotoxic drugs.

Common Exam Traps

• GFR <60 for 3 months confirms CKD — not a single low value.
• ACE inhibitors/ARBs slow progression but can cause hyperkalemia — monitor labs.
• Target hemoglobin in CKD anemia is 10–11 g/dL, NOT the normal range.
• Phosphate binders MUST be taken with meals to bind dietary phosphorus.
• Hyperkalemia → peaked T waves; hypocalcemia → prolonged QT.
• Peritoneal dialysis with cloudy outflow = peritonitis (priority!).

Key takeaways

• CKD is the irreversible loss of kidney function, staged 1–5 by GFR; diagnosis requires GFR <60 for ≥3 months.
• Diabetes and hypertension are the leading causes; target BP <130/80 with ACE inhibitors or ARBs.
• Hyperkalemia and fluid overload are the most immediate physiologic threats.
• Treat anemia with epoetin alfa to a target hemoglobin of 10–11 g/dL.
• Phosphate binders must be taken with meals; avoid NSAIDs and other nephrotoxins.
• Initiate dialysis for GFR <15 with symptoms, refractory fluid overload, or severe uremia/hyperkalemia.