What are the key components of medical management for patients with chronic kidney disease (CKD)?

From the Guidelines

Medical management of chronic kidney disease (CKD) should prioritize a comprehensive approach to reduce risks of kidney disease progression and cardiovascular disease, as outlined in the 2022 KDIGO clinical practice guideline for diabetes management in CKD 1. The key components of this approach include:

• Regular risk factor reassessment (every 3–6 months)
• Glycemic control with medications like SGLT2 inhibitors (empagliflozin 10-25 mg daily or dapagliflozin 5-10 mg daily) for diabetic patients, targeting HbA1c of 7-8%
• Blood pressure control using ACE inhibitors (like lisinopril 10-40 mg daily) or ARBs (such as losartan 25-100 mg daily)
• Lipid management with statin therapy (atorvastatin 20-40 mg daily)
• Lifestyle modifications such as smoking cessation, regular exercise, and dietary changes including sodium restriction (<2g/day), protein moderation (0.8g/kg/day for stages 1-4 CKD), and potassium restriction in advanced stages
• Addressing metabolic complications involves managing anemia, controlling mineral-bone disorders, and correcting metabolic acidosis
• Regular monitoring of kidney function, electrolytes, and complication markers, along with timely nephrology referral (typically at eGFR <30 ml/min/1.73m²) This comprehensive approach is supported by recent guidelines, including the 2022 KDIGO clinical practice guideline for diabetes management in CKD 1 and the 2020 KDIGO clinical practice guideline for the evaluation and management of CKD 1. Additionally, the American Diabetes Association and the European Association for the Study of Diabetes recommend the use of SGLT2 inhibitors and GLP-1 receptor agonists for patients with diabetic kidney disease to provide both kidney and cardiovascular protective benefits 1. It is essential to note that the management of CKD should be individualized, and the treatment strategy should be tailored to the patient's specific needs and clinical characteristics, as emphasized in the 2014 KDOQI US commentary on the 2012 KDIGO clinical practice guideline for the evaluation and management of CKD 1.

From the FDA Drug Label

2 DOSAGE AND ADMINISTRATION

1. 1 Important Dosing Information Evaluate the iron status in all patients before and during treatment. Administer supplemental iron therapy when serum ferritin is less than 100 mcg/L or when serum transferrin saturation is less than 20%. The majority of patients with CKD will require supplemental iron during the course of ESA therapy.

2. 2 Patients with Chronic Kidney Disease In controlled trials, patients experienced greater risks for death, serious adverse cardiovascular reactions, and stroke when administered ESAs to target a hemoglobin level of greater than 11 g/dL. No trial has identified a hemoglobin target level, ESA dose, or dosing strategy that does not increase these risks Individualize dosing and use the lowest dose of PROCRIT sufficient to reduce the need for RBC transfusions

The key components of medical management for patients with Chronic Kidney Disease (CKD) include:

• Evaluating and managing iron stores and nutritional factors
• Monitoring response to therapy, including hemoglobin levels and adjusting the dose as needed
• Individualizing dosing to use the lowest dose of ESA sufficient to reduce the need for RBC transfusions
• Considering the risks and benefits of ESA therapy, including the potential for increased risk of death and serious cardiovascular adverse reactions 2
• Avoiding frequent dose adjustments and not increasing the dose more frequently than once every 4 weeks
• Discontinuing ESA therapy if responsiveness does not improve
• Initiating ESA treatment when the hemoglobin level is less than 10 g/dL, and considering the rate of hemoglobin decline and the risk of alloimmunization and/or other RBC transfusion-related risks.

From the Research

Medical Management of Renal Patients

The medical management of patients with chronic kidney disease (CKD) involves several key components, including:

• Cardiovascular risk reduction, such as the use of statins and blood pressure management 3
• Treatment of albuminuria, such as the use of angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers 3, 4
• Avoidance of potential nephrotoxins, such as nonsteroidal anti-inflammatory drugs 3
• Adjustments to drug dosing, such as for many antibiotics and oral hypoglycemic agents 3
• Monitoring for complications of CKD, such as hyperkalemia, metabolic acidosis, hyperphosphatemia, vitamin D deficiency, secondary hyperparathyroidism, and anemia 3, 5

CKD Staging and Referral

CKD staging and referral to a nephrologist are important components of medical management, particularly for patients at high risk of CKD progression 3, 6. The use of combination angiotensin receptor blocker and angiotensin-converting enzyme inhibitor treatment may be beneficial for some patients with CKD 4.

Risk-Directed Management

Risk-directed management of CKD involves the use of prognostic estimates to guide therapy and prioritize care for patients at high risk of adverse events 7. This approach may involve the use of sodium-glucose co-transporter 2 inhibitors, glucagon-like peptide 1 receptor agonists, and mineralocorticoid receptor antagonists, in addition to angiotensin-converting enzyme inhibitors and angiotensin receptor blockers 7.

End-Stage Renal Disease Management

For patients with end-stage renal disease (ESRD), medical management involves referral to nephrology, optimization of disease management, and consideration of kidney transplantation or dialysis 5. Vaccination against certain infections, control of blood pressure, and monitoring for signs of protein-energy wasting and malnutrition are also important components of ESRD management 5.