From the Guidelines
The workup and management of Chronic Kidney Disease (CKD) should focus on identifying the underlying cause, assessing severity, and implementing strategies to slow progression and manage complications, as outlined in the most recent KDIGO 2024 clinical practice guideline 1.
Initial Evaluation
Initial evaluation includes comprehensive laboratory testing with:
- Serum creatinine
- Estimated glomerular filtration rate (eGFR)
- Urinalysis
- Urine albumin-to-creatinine ratio
- Complete blood count
- Electrolytes
- Renal ultrasound
Management
Management involves treating the underlying cause and addressing modifiable risk factors.
- Blood pressure control is essential, targeting <130/80 mmHg using ACE inhibitors (like enalapril 5-40 mg daily or lisinopril 10-40 mg daily) or ARBs (such as losartan 25-100 mg daily) as first-line agents, particularly in patients with albuminuria 1.
- Glycemic control in diabetic patients aims for HbA1c around 7%, often using SGLT2 inhibitors (empagliflozin 10-25 mg daily or dapagliflozin 5-10 mg daily) which offer renoprotective benefits 1.
- Lifestyle modifications include:
- Sodium restriction (<2g/day)
- Moderate protein intake (0.8g/kg/day)
- Smoking cessation
- Regular exercise
Complications Management
As CKD progresses, complications require specific management:
- Anemia with iron supplementation and erythropoiesis-stimulating agents when hemoglobin falls below 10 g/dL
- Mineral bone disorder with phosphate binders, vitamin D supplements, and calcimimetics
- Metabolic acidosis with oral sodium bicarbonate to maintain serum bicarbonate >22 mEq/L
- Cardiovascular risk reduction with statins
Monitoring and Referral
Regular monitoring of kidney function every 3-12 months (depending on CKD stage) allows for timely intervention, while nephrology referral is recommended for eGFR <30 mL/min/1.73m², rapid decline in kidney function, persistent albuminuria, resistant hypertension, or when planning for kidney replacement therapy in advanced disease 1.
From the Research
CKD Workup
- The typical workup for Chronic Kidney Disease (CKD) includes estimating the glomerular filtration rate (GFR) and assessing for albuminuria, which can be done through a urine albumin-to-creatinine ratio 2, 3.
- CKD is defined as a persistent abnormality in kidney structure or function, such as a GFR <60 mL/min/1.73 m2 or albuminuria ≥30 mg per 24 hours, for more than 3 months 2.
- Urinalysis is an important screening test to detect CKD, and proteinuria is a significant indicator of CKD, with a prevalence of 2.3% in the male population over 18 years old 4.
Management of CKD
- Optimal management of CKD includes cardiovascular risk reduction, treatment of albuminuria, avoidance of potential nephrotoxins, and adjustments to drug dosing 2.
- Patients with CKD require monitoring for complications such as hyperkalemia, metabolic acidosis, hyperphosphatemia, vitamin D deficiency, secondary hyperparathyroidism, and anemia 2.
- Lifestyle modifications, such as dietary changes, physical activity, and smoking cessation, are also recommended to slow the progression of CKD 5, 6.
- The use of sodium-glucose co-transporter 2 (SGLT2) inhibitors alongside a renin-angiotensin-aldosterone system inhibitor is recommended as foundational therapy for CKD management, particularly in people with and without type 2 diabetes 6.
Referral to Nephrologist
- Patients with CKD should be referred to a nephrologist if they have an estimated GFR <30 mL/min/1.73 m2, severe albuminuria, or acute kidney injury 2, 3.
- Early identification and management of CKD by primary care practitioners are crucial, and a multifaceted approach is required to ensure optimal kidney protection 6.