“I see CKD through a vascular lens. At every stage, the kidneys and blood vessels are damaging each other simultaneously — and at every stage, there is something that can be done.”
By Dr. Rahul Agarwal | Consultant Vascular & Endovascular Surgeon, CARE Hospitals, Banjara Hills, Hyderabad
Chronic kidney disease (CKD) is staged using eGFR — the estimated glomerular filtration rate. This number, derived from serum creatinine, reflects how well the kidneys are filtering blood. Understanding what each stage means — particularly for your blood vessels — is essential for CKD patients who want to take active control of their disease trajectory.
📊 CKD Stage 1: eGFR ≥ 90
Kidney function: Normal or high. Stage 1 requires evidence of kidney damage (protein in urine, blood in urine, imaging abnormalities) despite normal eGFR.
Vascular implications: Microalbuminuria — even at this stage — is an independent cardiovascular risk marker. Patients with Stage 1 CKD from diabetic nephropathy already have elevated cardiovascular risk. Endothelial dysfunction is detectable. This is the optimal stage for intervention.
Key action: Diagnose the cause, control blood pressure, start ACE inhibitor/ARB if proteinuria present, optimise glucose control, start statin if needed.
📊 CKD Stage 2: eGFR 60–89
Kidney function: Mildly reduced. Most patients are asymptomatic.
Vascular implications: Cardiovascular risk is measurably higher than the general population. Arterial stiffness is increasing. Renin-angiotensin system activation begins contributing to hypertension. Vein preservation counselling should begin now for any patient whose trajectory might require dialysis.
Key action: Continue risk factor management. Refer to nephrology for co-management. Begin vein preservation education.
📊 CKD Stage 3: eGFR 30–59 (3a: 45–59; 3b: 30–44)
Kidney function: Moderately reduced. Complications begin: anaemia (from reduced erythropoietin), bone disease (from reduced vitamin D activation and rising phosphate), hypertension worsening.
Vascular implications: Vascular calcification begins accelerating. PAD is more common than in the general population. Cardiovascular risk is 5–10x higher. For diabetic nephropathy patients, this is often the stage where foot complications first emerge.
Key action: Aggressive cardiovascular risk factor control. Correct anaemia and phosphate abnormalities. Serious discussion about dialysis planning. Formal vein preservation protocol begins. Annual foot examination for diabetics.
📊 CKD Stage 4: eGFR 15–29
Kidney function: Severely reduced. Uraemic symptoms may begin: fatigue, decreased appetite, nausea. Fluid retention. Electrolyte imbalances.
Vascular implications: Cardiovascular risk extremely high. Medial arterial calcification often significant, making ABI measurements unreliable in diabetics. Peripheral vascular disease may be present and symptomatic.
Key action: This is when the vascular surgeon must be involved. Referral for dialysis access planning, vein mapping, and fistula surgery to allow 6–12 weeks of maturation before dialysis starts.
📊 CKD Stage 5: eGFR < 15 (End-Stage Renal Disease)
Kidney function: Severely reduced or absent. Dialysis or transplant required for survival.
Vascular implications: All the cardiovascular risks of earlier stages are now compounded by dialysis-related haemodynamic changes. The AV fistula itself affects cardiac output. High-flow fistulas in patients with compromised cardiac function require monitoring.
Key action: Dialysis via functioning AV fistula (if surgery was timely). Continue aggressive cardiovascular risk management. Monitor fistula flow and cardiac function together.
❓ Frequently Asked Questions
My eGFR dropped from 65 to 55 over the last year. Should I be worried?
A drop of 10 mL/min/year is clinically significant and suggests active progression. This warrants nephrology review, investigation of reversible causes, and aggressive optimisation of risk factors. Not all eGFR decline is linear — some stabilises with treatment.
At which stage do I need to see a vascular surgeon?
Stage 4 (eGFR 15–29) is the referral stage for haemodialysis access planning. If your trajectory is steep, Stage 3b may warrant earlier discussion. A nephrologist will initiate this referral — if yours hasn’t by Stage 4, ask directly.
🔑 Key Insights: CKD Stage 1–2 warrants cardiovascular risk control and vein preservation education. Stage 3 brings significant vascular calcification and PAD risk — aggressive management is essential. Stage 4 is the vascular surgeon’s entry point for dialysis access planning. Stage 5 requires functioning AV fistula access. At every stage, blood vessels and kidneys are interacting — and at every stage, intervention reduces the damage.
📚 Related Reading
- Dialysis Access & AV Fistula Surgery
- When Should a CKD Patient See a Vascular Surgeon?
- Vein Preservation in CKD
👨⚕️ About the Author
Dr. Rahul Agarwal is a Consultant Vascular & Endovascular Surgeon at CARE Hospitals, Banjara Hills, Hyderabad. He manages the vascular consequences of CKD at all stages — from early vein preservation counselling to AV fistula surgery and post-dialysis fistula maintenance.
Medical Disclaimer: This article is intended for general patient education only and does not constitute individualised medical advice. Always consult a qualified medical professional for diagnosis and treatment specific to your condition.