Protocol · WHO PEN and HEARTS
Chronic kidney disease in first-level care
Chronic kidney disease (CKD) is silent until late. Diabetes and high blood pressure cause most of it, so the clinic finds it by testing the people it already sees. Good blood pressure and glucose control slow it down, and simple medicine safety protects the kidneys that remain.
- Based on WHO PEN and HEARTS
- For doctors, clinical officers and nurses
- Reviewed October 2026
1Who / when
- Adults with diabetes: test once a year with a urine albumin test and serum creatinine (eGFR), preferably both.
- Adults with hypertension, heart disease or stroke, HIV, or a family history of kidney disease: check creatinine and urine where available.
- Anyone with swelling, high BP, foamy urine or unexplained anaemia, nausea or itching.
Silent diseaseEarly CKD has no symptoms. Oedema is a late sign. Nausea, itching and poor appetite usually mean advanced disease.
2Red flags: refer now
- Little or no urine.
- Breathless with crackles, raised neck veins or swelling (fluid overload).
- Confusion, drowsiness, a flapping tremor (uraemia), or seizures.
- Potassium above 6.5 mmol/L, or any raised potassium with ECG changes, weakness or palpitations.
- eGFR below 30.
- BP 180/110 or higher with headache, breathlessness, blurred vision, confusion or reduced urine.
Refer the same day. A haemolysed blood sample can falsely raise potassium: if well with a normal ECG, repeat the test.
3Assess
- BP, weight, oedema, chest, signs of anaemia; urine dipstick for protein and blood.
- Serum creatinine and eGFR (calculated with a validated equation, usually CKD-EPI).
- Urine albumin: albumin-to-creatinine ratio (ACR) is best; protein-to-creatinine ratio or dipstick if not.
- Glucose or HbA1c, potassium, haemoglobin; HIV test if status unknown.
- Review every medicine, including herbal and bought remedies.
Confirm before labellingDiagnose CKD only when eGFR is below 60, or albuminuria is present, on two tests 1 to 3 months apart. One abnormal result may be an acute illness or dehydration.
4Classify
| Finding (confirmed) | Meaning | Action |
|---|---|---|
| eGFR below 30, or anuria | Severe CKD | Refer urgently |
| eGFR 30 to 59 | Moderate CKD | Treat; refer non-urgently for specialist review |
| ACR 30 mg/g (3 mg/mmol) or more; dipstick trace or 1+ and above | Moderately or severely increased albuminuria | ACE inhibitor; BP below 130/80; refer non-urgently |
| eGFR 60 or more and ACR below 30 mg/g | No CKD on these tests | Retest yearly if diabetes or hypertension |
5Treat
Slow it down
- Blood pressure: aim below 130/80 using an ACE inhibitor (an ARB if cough), adding a thiazide if needed. Follow your HEARTS protocol for doses.
- Before and a few weeks after starting or increasing an ACE inhibitor or ARB: check creatinine and potassium where available. Do not give potassium supplements with them.
- Diabetes: aim for good glucose control but avoid hypoglycaemia. Metformin is contraindicated when eGFR is below 30.
- Statin for people with diabetes aged over 40, or at high cardiovascular risk, per your HEARTS protocol.
- Stop tobacco; less than 5 g salt a day.
Protect the kidneys
- Avoid NSAIDs such as ibuprofen and diclofenac; they reduce kidney function and raise potassium.
- Check the dose of every renally cleared medicine against your national formulary.
- In vomiting, diarrhoea or dehydration, replace fluids promptly and review ACE inhibitors, ARBs, diuretics and metformin until well.
PregnancyDo not use ACE inhibitors or ARBs in pregnancy or in women who could become pregnant and are not using effective contraception.
6Follow-up
- Every month after starting or changing treatment until BP is controlled, then every 3 to 6 months.
- Creatinine (eGFR) and potassium at least yearly, and more often when eGFR is below 60 or on an ACE inhibitor, ARB or diuretic, as your national protocol advises.
- Urine albumin yearly.
- Each visit: BP, weight, oedema, medicines and supply.
7Counsel
- Your kidneys clean your blood. Damage happens slowly and silently, so tests are the only way to know.
- Taking your BP and diabetes tablets every day protects the kidneys.
- Do not take pain tablets such as ibuprofen or diclofenac, or herbal remedies, without asking a health worker.
- Eat less salt; stop smoking.
- Come back quickly if you pass very little urine, become very swollen or breathless, or feel confused.
Your kidneys are working less well than they should. We cannot undo it, but controlling your blood pressure and sugar, and avoiding some medicines, can slow it down a lot.
8When to refer
- Same day: any red flag above, including eGFR below 30 or no urine.
- eGFR 30 to 59, or moderately or severely increased albuminuria, for specialist assessment.
- BP above 130/80 despite two medicines taken correctly.
- CKD in pregnancy, or kidney disease with no clear cause (no diabetes or hypertension).
- End-stage disease needs dialysis or a transplant: where these exist, refer early so that the person and family can plan.
9Sources
- World Health Organization. Diagnosis and management of type 2 diabetes (HEARTS-D). 2020 (WHO/UCN/NCD/20.1). Diabetic kidney disease: annual screening, diagnosis on two tests 1 to 3 months apart, albuminuria categories, BP below 130/80 with an ACE inhibitor, metformin contraindication, urgent and non-urgent referral criteria.
- World Health Organization. Guideline for the pharmacological treatment of hypertension in adults. 2021. Lower systolic target suggested in CKD.
- World Health Organization. HEARTS technical package for cardiovascular disease management in primary health care: evidence-based treatment protocols. 2018 (WHO/NMH/NVI/18.2). Creatinine and potassium monitoring with ACE inhibitors, ARBs and diuretics; pregnancy caution.
- World Health Organization. WHO package of essential noncommunicable (PEN) disease interventions for primary health care. 2020 (ISBN 9789240009226). ACE inhibitor for persistent albuminuria; more frequent BP checks in CKD.
- World Health Organization. IMAI district clinician manual: hospital care for adolescents and adults, volume 1. 2011 (ISBN 9789241548281). Hyperkalaemia thresholds and causes (including ACE inhibitors and NSAIDs), haemolysed samples, signs of uraemia.
- World Health Organization. Guideline: sodium intake for adults and children. 2012.
Adapted from WHO guidance; not endorsed by WHO. This page paraphrases and adapts the WHO publications listed under Sources, which are licensed CC BY-NC-SA 3.0 IGO; the adapted text is shared under the same licence for non-commercial education. Reasoning GP is not affiliated with WHO or any other organisation named here. Use it alongside your national guidelines, essential medicines list and formulary, and your clinical judgement. Doses are given only where they come from a WHO source; otherwise follow your national guideline or formulary.