India is in the grip of a kidney disease crisis that most doctors are only now beginning to fully appreciate. Chronic Kidney Disease (CKD) affects an estimated 17% of Indian adults — roughly 220 million people — yet the majority remain undiagnosed until they are already in advanced stages. For a condition that is largely preventable and highly manageable when caught early, this is a clinical and public health failure that every practising physician in India bears responsibility for addressing. The Scale of CKD in India: Why This Matters Right Now India has the second-highest number of CKD patients globally after China. The primary drivers are the twin epidemics of Type 2 diabetes and hypertension, which together account for over 60% of all CKD cases in the country. Diabetic nephropathy alone is now the leading cause of end-stage renal disease (ESRD) in urban India. With dialysis costing ₹8,000–₹15,000 per month and kidney transplants largely inaccessible outside metro centres, early-stage intervention is not just clinically correct — it is the only economically viable path for most Indian patients. CKD Staging Every Clinician Must Know CKD is staged by eGFR (estimated Glomerular Filtration Rate) and albuminuria level using the KDIGO 2024 guidelines. Stage 1 (eGFR ≥90) and Stage 2 (eGFR 60–89) are often missed because patients are asymptomatic. Stage 3a and 3b (eGFR 30–59) are where most Indian patients first present to a GP or internist with fatigue or mild hypertension. By Stage 4 (eGFR 15–29) the window for meaningful slowing of progression has largely passed. Stage 5 (eGFR <15) requires renal replacement therapy. The critical clinical habit is to calculate eGFR — not just creatinine — for every patient with diabetes or hypertension at every annual review. High-Risk Patients Your OPD Is Likely Missing Beyond diabetes and hypertension, Indian doctors must screen aggressively for CKD in patients with a history of recurrent UTIs, obstructive uropathy, chronic NSAID use (a massively underappreciated cause in India), traditional herbal medicine use with nephrotoxic compounds, a family history of CKD or ESRD, prior episodes of acute kidney injury (AKI), and patients who have undergone contrast-enhanced CT scans repeatedly without renal monitoring. Practical Management: What to Do at Each Stage At Stage 1–2, the focus is aggressive risk factor control: target BP below 130/80 mmHg, HbA1c below 7%, and start SGLT2 inhibitors (empagliflozin or dapagliflozin) in all eligible diabetic CKD patients — the CREDENCE and DAPA-CKD trials firmly establish their nephroprotective benefit independent of glucose control. Finerenone is the newest addition for CKD with type 2 diabetes, shown to reduce progression and cardiovascular events. At Stage 3, limit nephrotoxin exposure, adjust all drug doses to eGFR, avoid iodinated contrast where possible, and refer to nephrology. At Stage 4, initiate education on renal replacement therapy options before the patient hits Stage 5 in crisis. Diet Counselling: The Questions Your Patients Ask Indian CKD patients and their families routinely arrive with conflicting advice from the internet, WhatsApp groups, and well-meaning relatives. The evidence-based answers: protein restriction (0.6–0.8 g/kg/day) is appropriate from Stage 3 onward but must be supervised to prevent malnutrition. Potassium restriction is needed when serum K+ exceeds 5.0 mEq/L — bananas, coconut water, tomatoes, and potatoes need to be discussed frankly. Phosphate restriction matters from Stage 3b. Common Indian foods high in phosphate include dal, nuts, seeds, and colas. A renal dietitian referral is ideal but rare outside metros — doctors must fill this gap practically. AKI-to-CKD Transition: India’s Underappreciated Crisis India has extremely high rates of community-acquired AKI due to diarrhoeal illnesses, leptospirosis, malaria, snakebite, and sepsis. Studies show that up to 30–40% of AKI survivors develop CKD within 2 years, yet most are discharged without a renal follow-up plan. Every patient who survives a hospitalisation for AKI should have a serum creatinine and urine ACR checked at 3 months and 12 months post-discharge. This single protocol change could prevent thousands of cases of advanced CKD annually in India. Q&A: What Indian Doctors Are Searching About CKD Q: Should I start ACE inhibitors or ARBs in all CKD patients? A: Yes, in CKD patients with diabetes or proteinuria (ACR >30 mg/g), ACE inhibitors or ARBs are first-line regardless of BP. They reduce intraglomerular pressure and slow proteinuria progression. Avoid combining both due to hyperkalemia risk. Monitor K+ and creatinine at 1–2 weeks after initiation. Q: Which common drugs are most dangerous in CKD and must be dose-adjusted? A: The most critical ones seen in Indian OPDs are metformin (stop if eGFR <30, use with caution 30–45), NSAIDs (avoid entirely from Stage 2 onward), aminoglycosides, contrast agents, lithium, digoxin, and many antibiotics including ciprofloxacin and nitrofurantoin. Nitrofurantoin is particularly dangerous in CKD as it loses efficacy and causes peripheral neuropathy — it is still widely prescribed for UTIs in India without eGFR checking. Q: When should a GP refer a CKD patient to a nephrologist? A: Refer urgently if eGFR <30, if there is rapidly declining eGFR (>5 ml/min/year), persistent heavy proteinuria (ACR >300), uncontrolled hypertension despite 3 agents, unexplained anaemia, hyperkalemia, or if the underlying cause is unclear. Early referral at Stage 3b is ideal rather than waiting for Stage 4–5 crisis. Q: Is anaemia management part of CKD management for non-nephrologists? A: Absolutely. Renal anaemia (normocytic, normochromic) starts appearing from Stage 3. First rule out iron deficiency — check ferritin and TSAT. If iron-replete and Hb <10 g/dL, erythropoiesis-stimulating agents (ESAs) may be considered, but this is typically a nephrology decision. Do not over-correct Hb above 11.5 g/dL as it increases cardiovascular events. How Doctrust Supports Your CKD Practice Managing CKD across a busy Indian OPD is complex — it demands structured follow-up, medication reviews at each visit, and clear documentation for medico-legal protection. Doctrust’s clinical workflow tools help you track eGFR trends, flag nephrotoxic drug interactions, and set automated follow-up reminders for your at-risk patients. Stop managing CKD on paper and start building a systematic, evidence-based renal care protocol for your clinic. Get a demo at www.doctrust.in