Reference — Renal
Kidney Disease Staging Reference
CKD stages 1–5 (KDIGO classification) — eGFR ranges, clinical implications, monitoring priorities, and nursing considerations for each stage of chronic kidney disease.
Educational use only. This material supports nursing education and exam review. It is not medical advice and is not a substitute for clinical judgment, institutional policy, or medical direction. Always follow facility protocols and current provider orders.
KDIGO 2022 Guidelines. CKD staging is based on eGFR (GFR category) and albuminuria (A category). eGFR alone classifies GFR category; damage markers are required for stage G1–G2 diagnosis. These are GFR categories — the full staging system also incorporates albuminuria risk categories (A1–A3).
Quick Reference: CKD Stages
| Stage | eGFR (mL/min) | Description | Key Action |
|---|---|---|---|
| G1 | ≥90 | Normal/high eGFR with damage markers | Treat cause, reduce CVD risk |
| G2 | 60–89 | Mildly decreased | Monitor annually |
| G3a | 45–59 | Mildly to moderately decreased | Nephrology referral, treat complications |
| G3b | 30–44 | Moderately to severely decreased | Stop metformin, strict dose adjustments |
| G4 | 15–29 | Severely decreased | Prepare for RRT, AV fistula creation |
| G5 | <15 | Kidney failure (ESRD) | Dialysis or transplant required |
Normal or High eGFR with Kidney Damage
eGFR: ≥90 mL/min/1.73m²
Kidney function is normal or above normal, BUT markers of kidney damage are present (albuminuria, structural abnormalities, hematuria, or known kidney disease).
Clinical Implications
- ✦Often completely asymptomatic
- ✦Diagnosis requires damage markers — albuminuria, abnormal imaging, or biopsy
- ✦Microalbuminuria (30–300 mg/day albumin) is the earliest detectable sign of diabetic nephropathy
- ✦Normal creatinine and BUN — eGFR ≥90 does NOT exclude CKD if damage markers present
Monitoring Priorities
- ✦Annual eGFR and urine albumin:creatinine ratio (UACR)
- ✦Blood pressure monitoring and control (target <130/80 mmHg)
- ✦Tight glucose control in diabetes (A1C per individualized target)
- ✦ACE inhibitor or ARB therapy for albuminuria (reno-protective)
- ✦Avoid nephrotoxic agents (NSAIDs, contrast agents, aminoglycosides)
Nursing Safety Note — Stage G1:
No dose adjustments needed at this stage. Educate about risk factor modification and monitoring.
Mildly Decreased
eGFR: 60–89 mL/min/1.73m²
Mildly reduced kidney function. Requires damage markers for CKD diagnosis (otherwise this eGFR is normal for elderly patients). Still largely asymptomatic.
Clinical Implications
- ✦Often asymptomatic — patients generally feel well
- ✦May have mild elevations in creatinine
- ✦Blood pressure elevation common
- ✦Proteinuria may be detectable
Monitoring Priorities
- ✦Annual nephrology evaluation or PCP follow-up
- ✦Monitor BP, urine protein, eGFR trend
- ✦Assess cardiovascular risk factors (most patients will die from CVD, not ESRD)
- ✦Continue ACE inhibitor/ARB if proteinuric
- ✦Encourage smoking cessation (significant risk factor for CKD progression)
Nursing Safety Note — Stage G2:
Most medications safe at this stage. Begin education about CKD, diet, and prevention of progression.
Mildly to Moderately Decreased
eGFR: 45–59 mL/min/1.73m²
Moderate CKD. Complications begin to emerge — anemia, early bone disease, and cardiovascular disease risk increase. Nephrology referral often initiated.
Clinical Implications
- ✦Anemia may develop (decreased EPO production)
- ✦Early secondary hyperparathyroidism (low vitamin D → ↑ PTH)
- ✦Hypertension often present or worsening
- ✦Fatigue, decreased exercise tolerance may begin
- ✦Significantly increased cardiovascular disease risk
Monitoring Priorities
- ✦Every 3–6 month labs: BMP, CBC, phosphorus, PTH, 25-OH vitamin D
- ✦Monitor for anemia — consider ESA therapy if Hgb <10 g/dL
- ✦Phosphate binders if phosphorus rising
- ✦Dietary counseling: moderate protein restriction, reduce phosphorus, sodium restriction
- ✦Nephrology referral at this stage is commonly recommended
Nursing Safety Note — Stage G3a:
Check metformin: safe down to eGFR 45, caution 30–45, CONTRAINDICATED <30. Avoid NSAIDs.
Moderately to Severely Decreased
eGFR: 30–44 mL/min/1.73m²
Advanced moderate CKD. Multiple complications present. Nephrology is managing care. Preparation for renal replacement therapy begins at this stage.
Clinical Implications
- ✦Symptomatic anemia common — may require ESA therapy
- ✦Metabolic acidosis may develop (bicarbonate replacement needed)
- ✦Hyperkalemia risk increases — dietary K⁺ restriction often needed
- ✦Renal bone disease progresses — bone pain, pathologic fractures possible
- ✦Hypertension often difficult to control
Monitoring Priorities
- ✦Every 3-month labs: BMP, CBC, phosphorus, PTH, albumin
- ✦Bicarbonate supplement if serum bicarb <22 mEq/L
- ✦ESA therapy with iron supplementation for anemia
- ✦Phosphate binders with meals
- ✦Dietary K⁺ restriction if K⁺ trending up
Nursing Safety Note — Stage G3b:
STOP metformin at eGFR <30. Dose-adjust: ACE inhibitors, ARBs (monitor K⁺ closely), digoxin, antibiotics (renal dose adjustments required for many). Avoid contrast without nephrology clearance.
Severely Decreased
eGFR: 15–29 mL/min/1.73m²
Severe CKD. Active preparation for renal replacement therapy. Multiple complications requiring management. Uremic symptoms may begin to appear.
Clinical Implications
- ✦Uremic symptoms may begin: fatigue, nausea, pruritus
- ✦Metabolic acidosis common — requiring bicarbonate supplementation
- ✦Hyperkalemia requires dietary restriction and possibly potassium-binding medications
- ✦Severe anemia common
- ✦Fluid overload risk
Monitoring Priorities
- ✦Monthly labs: BMP, CBC, phosphorus, PTH, albumin, bicarbonate
- ✦Vascular access surgery referral (AV fistula creation — takes 6–12 weeks to mature)
- ✦Transplant evaluation (living or deceased donor workup)
- ✦Peritoneal dialysis training if patient interested
- ✦Advance care planning discussions
- ✦Fluid restriction may be needed
Nursing Safety Note — Stage G4:
HIGH medication risk stage. Major dose adjustments required for nearly all renally cleared medications. Avoid ALL NSAIDs, contrast without coverage. Check renal dosing for every new medication.
Kidney Failure (ESRD)
eGFR: <15 mL/min/1.73m²
End-stage renal disease. The kidneys can no longer maintain life without renal replacement therapy. Dialysis or kidney transplant is required for survival.
Clinical Implications
- ✦Uremic syndrome: encephalopathy, pericarditis, bleeding, nausea/vomiting
- ✦Fluid overload — pulmonary edema if not dialyzing
- ✦Severe hyperkalemia — life-threatening cardiac risk
- ✦Severe metabolic acidosis
- ✦Severely impaired immune function
- ✦Profound anemia
Monitoring Priorities
- ✦Dialysis adequacy labs (Kt/V, URR) — monthly
- ✦Inter-dialytic weight gain (target <1 kg/day between sessions)
- ✦Potassium — pre-dialysis hyperkalemia is the most dangerous interval
- ✦Vascular access assessment at every encounter
- ✦Monitor for complications: infections, access failure, cardiovascular events
Nursing Safety Note — Stage G5:
ESRD patients on dialysis: 3× weekly hemodialysis sessions. Nearly all medications require renal dose adjustment. Assess fistula/graft/CVC at every encounter. Hepatitis B vaccination must have been completed before this stage for efficacy.
Related Resources
Standards & sources
Fact-checked Jun 21, 2026This page is written to align with KDIGO Clinical Practice Guidelines · National Kidney Foundation (NKF). It is an educational summary, not a citation of any single document — always verify specific doses, values, and protocols against current guidelines and your facility policy. How we source content →