Chronic kidney disease (CKD) affects a large share of adults worldwide and is rising, driven mainly by diabetes and high blood pressure. In parts of Africa and Asia, other causes such as glomerulonephritis, HIV-associated kidney disease, herbal remedy toxicity and some genetic factors also matter. Many people don’t know they have CKD until it is advanced. Access to dialysis varies widely, so prevention and early detection are vital.
CKD stages
CKD is classified by estimated glomerular filtration rate (eGFR) and the amount of protein (albumin) in the urine:
- G1: eGFR 90 or more, with other signs of kidney damage.
- G2: 60–89.
- G3a: 45–59; G3b: 30–44.
- G4: 15–29.
- G5: below 15 (kidney failure).
Slowing progression
- Blood pressure control, often with ACE inhibitors or ARBs, particularly if there is protein in the urine.
- Diabetes control. SGLT2 inhibitors are now recommended for many people with CKD to protect the kidneys.
- Stopping smoking, healthy weight, physical activity.
- Avoiding nephrotoxins: NSAIDs (ibuprofen, diclofenac), some herbal remedies, unnecessary contrast.
- Medicine dose adjustments for kidney function.
- Prompt treatment of acute kidney injury. See our AKI guide.
Complications of advanced CKD
- Fluid overload: oedema, breathlessness, hypertension.
- Hyperkalaemia: dangerous heart rhythm changes. See our electrolytes guide.
- Anaemia: kidneys make erythropoietin; treated with iron and erythropoiesis-stimulating agents.
- Mineral and bone disorder: high phosphate, low calcium; phosphate binders with meals.
- Metabolic acidosis.
- Uraemic symptoms: nausea, itching, poor appetite, fatigue, confusion.
- Greatly increased cardiovascular risk.
Kidney replacement options
- Haemodialysis: blood is filtered through a machine, usually three sessions a week of around 4 hours, via an arteriovenous fistula, graft, or central venous catheter.
- Peritoneal dialysis (PD): fluid is placed in the abdomen through a catheter and drained, done at home daily.
- Kidney transplant: the best long-term option for suitable patients.
- Conservative kidney management: supportive care without dialysis, a valid choice for some older or frail patients.
Protecting the fistula: “save the arm”
An arteriovenous fistula is a lifeline. On the fistula arm, and often on the non-dominant arm of people likely to need dialysis:
- No blood pressure measurements.
- No blood draws or cannulas (except by dialysis staff for dialysis).
- No tight clothing, watches or jewellery.
- Check daily for a thrill (buzzing felt with fingers) and bruit (whooshing heard with a stethoscope). Absence may mean clotting: report urgently.
- Watch for signs of infection or bleeding.
Fluid and diet
- Fluid restriction is common for haemodialysis patients, often based on urine output plus about 500 ml a day. Remember soups, ice and juicy fruit count.
- Tips for thirst: small cups, sucking ice chips (counted), sugar-free gum, limiting salt.
- Potassium restriction: certain fruits and vegetables (e.g. bananas, oranges, potatoes, tomatoes) may need limiting. Soaking or boiling vegetables can reduce potassium.
- Phosphate restriction: processed foods, colas, dairy, take binders with meals.
- Adequate protein, especially on dialysis. A renal dietitian is valuable.
- Daily weight: gain between dialysis sessions reflects fluid.
Ward nursing tips for dialysis patients
- Coordinate timing of dialysis with medicines; some are given after dialysis.
- Watch for hypotension and cramps after sessions.
- Ensure PD exchanges are done aseptically; cloudy PD fluid suggests peritonitis: report urgently.
- Check dialysis catheters for infection and keep them for dialysis use only.
Emotional support
Dialysis is demanding: hours each week tied to a machine, diet restrictions, cost, and loss of work. Depression is common. Ask how patients are coping and involve them in decisions, including advance care planning.
Based on KDIGO 2024 Clinical Practice Guideline for CKD, NICE NG203 and NICE NG107 (Renal replacement therapy). Educational content: follow local protocols.