Medications for CKD
For adults with CKD, hypertension, proteinuria, anemia, and mineral-bone disorder, initiate an SGLT2 inhibitor (if eGFR ≥20 ml/min/1.73 m²) combined with an ACE inhibitor or ARB, and add targeted therapies for anemia (ESAs if needed) and mineral-bone disorder (phosphate binders, vitamin D analogs, and calcimimetics as indicated by lab values).
Core Medication Framework
First-Line: SGLT2 Inhibitors
- Start an SGLT2 inhibitor immediately for any adult with CKD and eGFR ≥20 ml/min/1.73 m² who has proteinuria (ACR ≥200 mg/g), regardless of diabetes status 1
- For eGFR 20-45 ml/min/1.73 m² with ACR <200 mg/g, SGLT2i is still recommended but with slightly less strong evidence (2B recommendation) 1
- Continue the SGLT2i even if eGFR drops below 20 ml/min/1.73 m² unless not tolerated or dialysis is initiated 1
- Withhold temporarily during prolonged fasting, surgery, or critical illness due to ketosis risk 1
- The initial reversible eGFR decline after starting SGLT2i is expected and not a reason to stop 1
Second-Line: RAS Inhibition
- Continue ACE inhibitor or ARB even when eGFR falls below 30 ml/min/1.73 m² 1
- These medications provide both blood pressure control and proteinuria reduction 2
- Target blood pressure should be ≤130/80 mmHg with proteinuria reduced to <0.5 g/day 3
Third-Line: Nonsteroidal MRA (for Persistent Albuminuria)
- Add finerenone if albuminuria persists (>30 mg/g) despite maximum tolerated RAS inhibitor in patients with type 2 diabetes, eGFR >25 ml/min/1.73 m², and normal potassium 1
- Can be combined with both RASi and SGLT2i 1
Dosing algorithm for finerenone:
- If K⁺ ≤4.8 mmol/L: Start 10 mg daily (eGFR 25-59) or 20 mg daily (eGFR ≥60)
- If K⁺ 4.9-5.5 mmol/L: Continue current dose, monitor every 4 months
- If K⁺ >5.5 mmol/L: Hold medication, adjust diet/medications, restart at 10 mg when K⁺ ≤5.0 mmol/L 1
Anemia Management
- Erythropoiesis-stimulating agents (ESAs) are the mainstay for renal anemia 4, 5
- Avoid overly aggressive hemoglobin targets due to cardiovascular risks 4
- Iron supplementation should accompany ESA therapy
Mineral-Bone Disorder Management
Phosphate control:
- Phosphate binders are first-line for hyperphosphatemia 4, 6
- Target normal serum phosphate levels to prevent secondary hyperparathyroidism 5, 7
Calcium and PTH management:
- Correct hypocalcemia with calcium supplementation 7
- Vitamin D analogs for vitamin D deficiency and elevated PTH 6, 7
- Calcimimetics for refractory secondary hyperparathyroidism 6
Metabolic acidosis:
- Sodium bicarbonate supplementation may slow CKD progression and should be considered 4
Additional Considerations
GLP-1 Receptor Agonists
- If glycemic targets not met despite metformin and SGLT2i (or if these cannot be used), add a long-acting GLP-1 RA in patients with type 2 diabetes 1
Cardiovascular Risk Management
- Statins for dyslipidemia are important given the excessive cardiovascular mortality in CKD patients 4, 5
- Address smoking cessation, obesity, and hyperuricemia as modifiable risk factors 8
Critical Monitoring Parameters
- Potassium levels: Check 1 month after MRA initiation, then every 4 months 1
- eGFR and proteinuria: Regular monitoring but don't stop SGLT2i for expected initial eGFR dip 1
- Phosphate, calcium, PTH, and vitamin D: Monitor to guide mineral-bone disorder therapy 7, 9
- Hemoglobin: Guide anemia management 4
Common Pitfalls
- Don't discontinue ACEi/ARB when eGFR drops below 30 - this is outdated practice 1
- Don't stop SGLT2i for the initial reversible eGFR decline - this is expected and beneficial long-term 1
- Don't ignore hyperkalemia risk with MRA - requires consistent normal baseline potassium and regular monitoring 1
- Don't delay nephrology referral - multidisciplinary management improves outcomes 8