Chronic kidney disease is a category of kidney dysfunction, characterised by irreversible changes to kidney structure and a reduction in kidney function. This is a Self-assessment article

and comes with a self-assessment test Nursing Times Self-assessment articles offer bitesize CPD and are accompanied by multiple-choice assessments with feedback. Test yourself on this

article or click here to choose other subjects from the Self-assessment archive. ABSTRACT This fourth article in a series about the renal system examines chronic kidney disease. The

condition’s epidemiology, causes and clinical markers, as well as the approach to diagnosis are explored. Also discussed is the current staging criteria and how this, alongside

University. INTRODUCTION There are three main categorisations of kidney dysfunction, as introduced in the second article in this series (Taylor, 2023a). These are: * Acute kidney disease and

disorders (AKD); * Acute kidney injury (AKI); * Chronic kidney disease (CKD). The last of these, CKD, is explored in this article. CKD is characterised by changes to the structure of the

kidney and a reduction in normal kidney function that persists for >3 months. This reduced function is the result of a gradual loss of nephrons; these are the units of the kidneys that

are responsible for several key functions, including the removal of waste products from the blood through the formation of urine (Taylor, 2023b). CKD affects health over several months to

years, resulting in impaired tubular activity and overall kidney function, as well as reduced endocrine functionality (Cook et al, 2022). Unlike the acute categorisations of kidney

dysfunction, the damage to, and loss of, functionality that occur with CKD are irreversible; as a result, treatment often aims to manage underlying causes and complications to prevent

progression (Cook et al, 2022). However, CKD progresses slowly, typically presenting very few symptoms in its initial stages, which makes early detection and diagnosis difficult (Fattah et

al, 2019). It has a range of causes and, in some cases, AKD and/or AKI act as a foundation for its development, with studies also showing that AKI can accelerate its progression (Hsu and

Hsu, 2016). Increased awareness and early detection of CKD are, therefore, crucial in ensuring better patient outcomes through earlier intervention. EPIDEMIOLOGY OF CKD Due to healthcare

improvements and an ageing population, CKD is a condition of increasing concern because it poses considerable long-term challenges for healthcare sectors worldwide (Elshahat et al, 2020).

Globally, between 1990 and 2017, the number of CKD cases increased by 29.3%, and there was an increase in CKD-associated mortality of 41.5%. Due to this increase, CKD was, in 2017, the

12th-highest cause of death globally, accounting for 4.6% of all deaths (Cockwell and Fisher, 2020). An analysis by the Global Burden of Disease Chronic Kidney Disease Collaboration

(GBDCKDC), which builds on its earlier study, reported an estimated global prevalence of the disease in 2017 of 9.1% (approximately 697.5 million cases) (GBDCKDC, 2020). In England, the

prevalence of CKD in people aged ≥35 years old is around 15%, with the annual cost to the NHS of managing the condition estimated to be £1.4bn (Hirst et al, 2020). In 2017, CKD was

responsible for 1.2 million deaths globally, with a number of these attributed to cardiovascular incidents, including myocardial infarction and stroke (GBDCKDC, 2020; Hirst et al, 2020). CKD

prevalence and the nature of its progression vary between, and within, countries due to determinants of health, including cultural background, ethnicity, wealth and social factors (Webster

et al, 2017). To manage CKD more effectively worldwide, it is crucial to understand the true scale of the problem; this requires consensus in the: * Criteria used to diagnose the condition;

* Reporting framework used; * Approach to how deaths attributable to CKD are recorded. People with CKD are at increased risk of developing diabetes, heart disease and other complications,

and recent studies have highlighted links between CKD and increased severity and mortality of Covid-19 (Dashtban et al, 2022). A study by Bowe et al (2021) also observed that people with

long Covid have a greater risk of developing AKI and experiencing a more rapid decline in glomerular filtration rate (GFR). Findings such as these are key to informing health policy and

management globally, nationally and locally, by supporting longer-term decision making about aspects such as resource allocation (GBDCKDC, 2020). > _“To manage CKD more effectively 

worldwide, it is crucial to > understand the true scale of the problem”_ CAUSES OF CKD There are various causes of CKD; as mentioned above, the prevalence of these varies between

settings. In middle- to high-income countries, such as the UK, the primary causes are diabetes and hypertension (Webster et al, 2017); collectively, these account for approximately

two-thirds of all CKD cases in these regions (Wouters et al, 2015). Currently, diabetes mellitus is the leading cause of CKD; ~40% of people with type 1 and type 2 diabetes go on to develop

CKD worldwide (Tang et al, 2022). Hypertension is another condition of growing concern globally, primarily due to increasing obesity rates and an ageing population. It is also a known risk

factor for, and cause of, both renal dysfunction and cardiovascular disease (Ren et al, 2021). Greater awareness, and earlier detection and treatment of these conditions could help prevent

the development of such complications. Less common causes of CKD include hydronephrosis (typically the result of urinary obstruction), glomerulonephritis and polycystic kidney disease

(Wouters et al, 2015). In developing countries, a higher prevalence of CKD has been associated with exposure to: * Heavy metals; * Various nephrotoxins; * HIV (GBDCKDC, 2020). In people with

diabetes, hyper- glycaemia can cause changes to the microvasculature structure of the kidneys; this is the network of arterioles, venules and capillaries that regulate blood perfusion and

substance exchange between blood and tissue (Cook et al, 2022). The glomerular capillaries and the afferent and efferent arterioles are also typically affected (Cook et al, 2022). If

sustained, the changes that occur can result in an overall thickening of the glomerular capillaries, due to the deposition of proteins and antibodies; this can lead to the development of

glomerulosclerosis (Cook et al, 2022). Another major cause of CKD is AKI. People who have had AKI are more likely to experience repeat episodes of the condition, which, in turn, increases

their risk of developing CKD. In particular, people who develop AKI following major surgery have an eight-fold risk of developing CKD and its associated complications, when compared with

patients without AKI (Meersch et al, 2017). DETECTION AND DIAGNOSIS OF CKD CKD progression is associated with a decline in overall kidney function, resulting from the progressive loss of

nephrons. However, because the kidneys are capable of accommodating a degree of nephrotic loss through adaptive structural changes to the remaining nephrons, CKD presents very few clear

symptoms during its initial stages, making diagnosis difficult (Fattah et al, 2019). When symptoms are present, they tend to be non-specific and often point to the underlying cause of the

condition, with CKD only diagnosed later after exploratory analysis of blood and urine for the presenting symptoms (Fattah et al, 2019). To improve long-term patient outcomes, both increased

awareness of CKD and greater research into novel methods for its early detection and diagnosis are crucial. This is particularly important because CKD is irreversible and impairs quality of

life, both physically and psychologically, especially in its later stages when kidney function is progressively reduced. As noted in the second article in this series, several criteria are

used to diagnose and determine the stage of progression of kidney dysfunction. The current consensus on the staging of CKD is primarily concerned with GFR and the urinary albumin–creatinine

ratio (ACR); however, other elements are commonly used to aid diagnosis, including patient history (Taylor, 2023b). In urine, the presence of albumin (albuminuria) and overall protein

(proteinuria) are important indicators used to help track the progression of CKD (Schneider et al, 2021). Levey et al (2020) noted that the organisation Kidney Disease: Improving Global

Outcomes (KDIGO) provided the current, widely accepted definition of CKD as a GFR of <60ml per minute per 1.73m2 or the presence of ≥1 indicative markers of kidney damage for >3

months. These markers include: * Albuminuria; * Presence of abnormal sediment in urine; * Histological anomalies; * History of kidney transplant (KDIGO, 2013). GFR AND ESTIMATED GFR GFR is a

measure of the rate of filtrate production by the kidneys, as waste products are filtered out of the blood during glomerular filtration. GFR has long been used in the diagnosis and staging

of kidney dysfunction as it can provide vital insight into how effectively the kidneys are working. Often used in place of GFR is estimated GFR (eGFR) – this is an estimate of the value,

which is calculated based on criteria including sex, age, race and serum creatinine level (Cook et al, 2022). > _“It is important that nurses are aware that people diagnosed with > 

early stage CKD still experience symptoms that can affect quality of > life”_ ACR In practice, the significance of the presence of protein in the urine is expressed as either the ACR or

the protein–creatinine ratio. ACR is the widely preferred means of quantification; KDIGO’s (2013) guidelines for diagnosing and staging CKD specify that it should be used due to its

increased sensitivity for lower levels of protein. ACR is calculated by dividing the urinary concentrations of albumin (in milligrams) by creatinine (in grams). Healthy adults typically have

an ACR of <30mg/g (Ren et al, 2021). Even when eGFR is found to be within the normal or expected range, an elevated ACR (≥30mg/g) can indicate kidney damage. Zhang et al’s (2022) study

showed a link between a high ACR and increased risk of cardiovascular-related mortality, especially in people who have or have a family history of diabetes or hypertensive disorders. STAGES

OF PROGRESSION OF CKD Diagnosing and staging CKD, as well as assessing the risk of it progressing, were originally based on GFR; a GFR value of <60ml per minute per 1.73m2 still remains a

key indicator (KDIGO, 2013). However, studies such as that by Tang et al (2022) have found that considering the ACR alongside the GFR can greatly help with the prediction of mortality and

cardiovascular complications. Even when GFR is within the normal range, an elevated ACR of ≥30mg/g can be a key indicator of kidney damage (KDIGO, 2013), so the use of both GFR and ACR is

vital to gain a more informed picture of the condition. For this reason, the current guidelines by KDIGO assess stage and likelihood of CKD progression using both GFR and ACR (Table 1).

KDIGO’s (2013) system uses colour gradation as an indicator of likelihood of progression: green denotes no CKD, unless there are indicators of kidney disease present, such as albuminuria;

yellow represents a moderate risk; and orange a high risk. During these earlier stages, there are usually no clear signs or symptoms of CKD, making diagnosis difficult. Red denotes a very

high risk of progression, at which point there are often clearer signs and symptoms. During this later stage, health professionals often discuss kidney replacement therapy (KRT) with the

patient, including dialysis and kidney transplant surgery. The key to better CKD patient outcomes is an increased awareness of the condition, its signs and diagnostic markers. Quicker

detection, diagnosis and staging are essential to earlier intervention and more successful management of the condition. > _“In recent years, there have been considerable developments in

> the approval of new drugs to manage and treat CKD”_ CKD MANAGEMENT AND TREATMENT Due to the lack of clear signs and symptoms, and the relatively minimal impact that can be felt during

CKD’s initial stages, it is not uncommon for patients to go undiagnosed until the condition is in the more advanced stages (Singh and Krause, 2023); at this point, it often has a greater

impact on patients’ health and overall quality of life. It is important that nurses are aware, however, that people who are diagnosed with early stage CKD can still experience symptoms that

can affect quality of life. These include changes in frequency of urination, oedema (particularly of the hands and feet), proteinuria and haematuria. Symptom management varies, depending on

the CKD’s underlying cause (American Kidney Fund, 2022). The risk of progression increases with CKD stage and, as the stage increases, so do its impacts on the urinary system and wider

bodily systems; this has significant consequences for overall health and wellbeing. Due to the irreversible nature of CKD, much of the approach to treatment is concerned with symptom

management and treating its underlying causes to minimise the risk of progression. Core to nursing practice, therefore, are a patient-centred approach to CKD and an awareness of the

condition that facilitates early detection and treatment. Irrespective of CKD stage, there are some commonalities in treatment approach, including: * Monitoring kidney function; * Monitoring

cardiovascular function; * Assessing risk factors (including hypertension); * Where applicable, providing lifestyle advice on smoking, weight, diet and physical activity (Cook et al, 2022).

As CKD progression is highly variable between patients, they should receive regular assessment of GFR, ACR and other indicative factors of CKD (Weir and Methven, 2020). Regular monitoring

and recording of any changes, however slight, can provide valuable insight into their overall health and disease progression. Hypertension, one of the primary risk factors of CKD, can be

both a cause and effect, and affects the majority of people with the condition (Pugh et al, 2019). CKD-associated mortality is rarely the result of the condition progressing to kidney

failure; rather, most CKD-related deaths are attributed to associated cardiovascular complications (Lamprea-Montealegre et al, 2021). Therefore, in all stages of CKD, part of the treatment

approach typically concerns actions to reduce the patient’s risk of developing cardiovascular disease (CVD). Although often used in other cases, for patients deemed to have a 10-year risk of

developing CVD, antiplatelet and lipid-lowering medications are used prophylactically (Cook et al, 2022). There is, however, limited clinical trial evidence supporting the effectiveness of

antiplatelet medications as a primary means of prevention, so this is a key area in which further research is needed (Ali et al, 2019). Lipid-lowering agents have been shown to reduce CVD

risk and are commonly used for all CKD patients who are not receiving KRT, a categorisation previously referred to as non-dialysis-dependent CKD (Levey et al, 2020; Ali et al, 2019). Current

guidelines on hypertension in CKD recommend a target blood pressure of <130/80mmHg, with renin-angiotensin-aldosterone system (RAAS) inhibitors often used to achieve this (Taylor, 2023b;

Ali et al, 2019). In addition, RAAS inhibitors, such as angiotensin-converting enzyme inhibitors and angiotensin-receptor blockers, have been shown to reduce the risk of CKD progressing to

kidney failure, with the greatest benefits seen in people who have high levels of albuminuria (Lamprea-Montealegre et al, 2021). In patients who have CKD as a result of diabetes,

multimorbidity is common: these patients have a higher risk of cardiovascular complication and a 12-fold risk of progression to kidney failure (Pálsson and Patel, 2014). This situation

requires a multidisciplinary approach to management and treatment, involving primary care, nephrologists, cardiologists and endocrinologists (Navaneethan et al, 2021). Managing the diabetes

also requires: * Careful control of blood–glucose levels, often using personalised HbA1c targets; * Lifestyle changes relating to physical activity, diet and weight (Triozzi et al, 2021); *

Actions to reduce the risk of CVD developing, to help prevent CKD progression. In recent years, there have been considerable developments in the approval of new drugs to manage and treat

CKD. Finerenone (Kerendia) is a non-steroidal mineralocorticoid receptor antagonist that has been shown to reduce the risk of cardiovascular complications and CKD progression in patients who

have both CKD and type 2 diabetes (Agarwal et al, 2022). Further studies have shown that finerenone can reduce albuminuria and promote improved cardiorenal heath status in patients who have

GFR stage 3-4 CKD and type 2 diabetes (Bakris et al, 2020). Although much promise has been shown in this area, further research is needed to investigate the long-term effectiveness on

cardiorenal health (Bakris et al, 2020). If CKD progresses to the later stages, with greatly reduced kidney function, there are two primary KRT options: * Dialysis; * Kidney transplant.

Patients with CKD who develop superimposed AKI have a greatly increased risk of CKD progression (Hsu and Hsu, 2016) and are more likely to require KRT (Weir and Methven, 2020). DIALYSIS

Dialysis artificially filters the blood to remove waste products, toxins and excess fluid. There are several forms, but the most prominent are: * Haemodialysis (HD); * Peritoneal dialysis

(PD). In its current guidance, the National Institute for Health and Care Excellence (NICE) (2018) recommends that dialysis is started when one of the following situations occurs: * The

symptoms of uraemia are assessed as having an impact on daily life; * Fluid balance is no longer being effectively maintained; * eGFR drops to 5-7ml per minute per 1.73m2. HD is the most

common form of dialysis and uses a haemodialysis machine to filter waste products from the blood (Fig 1). For most patients, an arteriovenous fistula is first formed in the arm to provide

access to the blood supply. From here, blood is passed via a filter called a dialyser, which removes waste products and excess fluid and passes them into the dialysis fluid before the blood

is returned to the body. HD can be carried out both in dialysis centres and at home; most patients undergo a four-hour session three times a week (NHS, 2021). PD uses the patient’s

peritoneal membrane to filter waste products from the blood. Dialysis fluid is introduced into the peritoneal cavity via a catheter, allowing waste products to be filtered from the blood and

drawn into the dialysis fluid (Fig 2). Dialysis fluid is typically replaced every 4-6 hours, taking place around four times a day. A fluid change takes approximately 30-40 minutes (NHS,

2021). PD is generally considered preferable for people undergoing dialysis for the first time, because residual renal function is maintained and haemodynamic stability is preserved

(Maruyama et al, 2019). Furthermore, a recent meta-analysis found that, although both HD and PD improve renal function, PD is superior because it has a reduced risk of infection and helps

improve nutrition status (Lu et al, 2022). KIDNEY TRANSPLANT Patients with CKD – particularly those with kidney failure – experience significant physical and psychological stress, resulting

in a greatly reduced quality of life. This has been linked to increased hospital stay, morbidity and mortality (Ryu et al, 2021). For people with kidney failure, transplant surgery can

vastly improve kidney function, resulting in increased survival rates and a better overall quality of life when compared with dialysis (Azegami et al, 2023). Organ donation is possible from

either a living or recently deceased individual, but outcomes that are more successful are those following a living donation from a close relative, due to reduced risk of the organ being

rejected (Cook, 2022). The length of time for which a transplanted kidney can be expected to function depends on several factors, including the: * Age and general health of the donor and

recipient; * Health of the donor organ. On average, a kidney from a living donor lasts 20-25 years, and a kidney from a recently deceased person lasts 15-20 years (NHS Blood and Transplant,

nd). Although transplantation is often seen as an option for people with kidney failure, it provides the best long-term outcomes when carried out earlier, in patients who have not progressed

to this stage of CKD. This approach can allow patients to avoid the pressures of dialysis, and it has been associated with improved survival rates of both the transplanted organs and

patients themselves (Azegami et al, 2023). Despite the clear benefits, however, not all patients with CKD are suitable for kidney transplant surgery. Those with certain comorbidities are

less likely to tolerate the procedure and are at increased risk of mortality; this includes people with severe cardiac disorders, pulmonary disorders or cancer (Abramyan and Hanlon, 2023).

> _“Transplant outcomes that are more successful are seen following > a living donation from a close relative, due to reduced risk of the > organ being rejected”_ CONCLUSION

Diabetes and hypertension are the main causes of CKD in middle- to high-income countries. Less common causes include hydronephrosis, glomerulonephritis and polycystic kidney disease. To

assess the risk of CKD progression, KDIGO criteria relating to the patient’s GFR and ACR are used. As CKD often presents few symptoms in its early stages, which makes detection and diagnosis

difficult, a patient-centred approach is essential. To facilitate earlier detection and treatment, health professionals need good awareness of CKD, including its risk factors, clinical

signs, symptoms and diagnostic markers. KEY POINTS * Chronic kidney disease is characterised by irreversible changes to kidney structure and a reduction in kidney function * Its primary

causes in middle- to high-income countries are diabetes and hypertension * Glomerular filtration rate and the urinary albumin–creatinine ratio are used to diagnose and determine its stage of

progression * Treatment aims to manage symptoms and any underlying causes to help minimise the risk of progression * In later stages, kidney replacement therapy can be used, either through

dialysis or kidney transplant surgery ALSO IN THIS SERIES * Test your knowledge with Nursing Times Self-assessment after reading this article. If you score 80% or more, you will receive a

personalised certificate that you can download and store in your Nursing Times Portfolio as CPD or revalidation evidence. * Take the Nursing Times Self-assessment for this article REFERENCES

ABRAMYAN S, HANLON M (2023) _Kidney Transplantation_. StatPearls Publishing. AGARWAL R ET AL (2022) Cardiovascular and kidney outcomes with finerenone in patients with type 2 diabetes and

chronic kidney disease: the FIDELITY pooled analysis. _European Heart Journal_; 43: 6, 474-484. ALI S ET AL (2019) Primary and secondary prevention of cardiovascular disease in patients with

chronic kidney disease. _Current Atherosclerosis Reports_; 21: 9, 32. AMERICAN KIDNEY FUND (2022) Stages of kidney disease. _kidneyfund.org_, 26 October (accessed 17 April 2023). AZEGAMI T

ET AL (2023) Efficacy of pre-emptive kidney transplantation for adults with end-stage kidney disease: a systematic review and meta-analysis. _Renal Failure_; 45: 1, 2169618. BAKRIS GL ET AL

(2020) Effect of finerenone on chronic kidney disease outcomes in type 2 diabetes. _New England Journal of Medicine_; 383: 23, 2219-2229. BOWE B ET AL (2021) Kidney outcomes in long Covid.

_Journal of the American Society of Nephrology_; 32: 11, 2851-2862. COCKWELL P, FISHER L-A (2020) The global burden of chronic kidney disease. _The Lancet_; 395: 10225, 662-664. COOK N ET AL

(2022) Disorders of renal function and fluid balance. In: _Essentials of Pathophysiology for Nursing Practice_. Sage Publications. DASHTBAN A ET AL (2022) A retrospective cohort study

predicting and validating impact of the Covid-19 pandemic in individuals with chronic kidney disease. _Kidney International_; 102: 3, 652-660. ELSHAHAT S ET AL (2020) The impact of chronic

kidney disease on developed countries from a health economics perspective: a systematic scoping review. _PLoS One_; 15: 3, e0230512. FATTAH H ET AL (2019) How do kidneys adapt to a deficit

or loss in nephron number? _Physiology_; 34: 3, 189-197. GBD CHRONIC KIDNEY DISEASE COLLABORATION (2020) Global, regional, and national burden of chronic kidney disease, 1990-2017: a

systematic analysis for the Global Burden of Disease Study 2017. _The Lancet_; 395: 10225, 709-733. HIRST JA ET AL (2020) Prevalence of chronic kidney disease in the community using data

from OxRen: a UK population-based cohort study. _British Journal of General Practice_; 70: 693, e285-e293. HSU RK, HSU C-Y (2016) The role of acute kidney injury in chronic kidney disease.

_Seminars in Nephrology_; 36: 4, 283-292. KIDNEY DISEASE: IMPROVING GLOBAL OUTCOMES (2013) KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease.

_Kidney International Supplements_; 3: 1, 1-150. LAMPREA-MONTEALEGRE JA ET AL (2021) Chronic kidney disease detection, staging and treatment in cardiovascular disease prevention. _Heart_;

107: 16, 1282-1288. LEVEY AS ET AL (2020) Nomenclature for kidney function and disease: report of a Kidney Disease: Improving Global Outcomes (KDIGO) consensus conference. _Kidney

International_; 97: 6, 1117-1129. LU J ET AL (2022) Comparative analysis of efficacy and prognosis of hemodialysis and peritoneal dialysis for end-stage renal disease: a meta-analysis.

_Computational and Mathematical Methods in Medicine_; 2022: 6007698. MARUYAMA Y ET AL (2019) Comparison of peritoneal dialysis and hemodialysis as first renal replacement therapy in patients

with end-stage renal disease and diabetes: a systematic review. _Renal Replacement Therapy_; 5: 44. MEERSCH M ET AL (2017) Perioperative acute kidney injury: an under-recognized problem.

_Anesthesia and Analgesia_; 125: 4, 1223-1232. NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE (2018) _Renal Replacement Therapy and Conservative Management_. NICE. NAVANEETHAN SD ET AL

(2021) Diabetes management in chronic kidney disease: synopsis of the 2020 KDIGO clinical practice guideline. _Annals of Internal Medicine_; 174: 3, 385-394. NHS (2021) Overview: dialysis.

_nhs.uk_, 29 September (accessed 11 April 2023). NHS BLOOD AND TRANSPLANT (nd) Living donor kidney transplant. _nhsbt.nhs.uk_ (accessed 11 April 2023). PÁLSSON R, PATEL UD (2014)

Cardiovascular complications of diabetic kidney disease. _Advances in Chronic Kidney Disease_; 21: 3, 273-280. PUGH D ET AL (2019) Management of hypertension in chronic kidney disease.

_Drugs_; 79: 4, 365-379. REN F ET AL (2021) Urine albumin-to-creatinine ratio within the normal range and risk of hypertension in the general population: a meta-analysis. _The Journal of

Clinical Hypertension_; 23: 7, 1284-1290. RYU J-H ET AL (2021) Better health-related quality of life in kidney transplant patients compared to chronic kidney disease patients with similar

renal function. _PLoS One_; 16: 10, e0257981. SCHNEIDER MF ET AL (2021) Estimation of albumin-creatinine ratio from protein-creatinine ratio in urine of children and adolescents with CKD.

_American Journal of Kidney Diseases_; 77: 5, 824-827. SINGH M, KRAUSE MW (2023) Chronic kidney disease. _bestpractice.bmj.com_, 9 February (accessed 29 February 2023). TANG W-H ET AL (2022)

The lower limit of reference of urinary albumin/creatinine ratio and the risk of chronic kidney disease progression in patients with type 2 diabetes mellitus. _Frontiers in Endocrinology_;

13: 858267. TAYLOR J (2023a) Renal system 2: acute kidney injury and other types of kidney dysfunction. _Nursing Times_; 119: 3, 48-53. TAYLOR J (2023b) Renal system 1: the anatomy and

physiology of the kidneys. _Nursing Times_; 119: 2, 30-34. TRIOZZI LJ ET AL (2021) Management of type 2 diabetes in chronic kidney disease. _BMJ Open Diabetes Research and Care_; 9:

e0002300. WEBSTER AC ET AL (2017) Chronic kidney disease. _The Lancet_; 389: 10075, 1238-1252. WEIR VA, METHVEN S (2020) A practical guide to diagnosis and assessment of chronic kidney

disease for the non-nephrologist. _Journal of the Royal College of Physicians of Edinburgh_; 50: 1, 67-74. WOUTERS OJ ET AL (2015) Early chronic kidney disease: diagnosis, management and

models of care. _Nature Reviews: Nephrology_; 11: 8, 491-502. ZHANG A ET AL (2022) The relationship between urinary albumin to creatinine ratio and all-cause mortality in the elderly

population in the Chinese community: a 10-year follow-up study. _BMC Nephrology_; 23: 16.   HELP NURSING TIMES IMPROVE HELP US BETTER UNDERSTAND HOW YOU USE OUR CLINICAL ARTICLES, WHAT YOU

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