What are the treatment guidelines for Chronic Kidney Disease (CKD)?

From the Guidelines

The treatment of Chronic Kidney Disease (CKD) should focus on slowing disease progression, managing complications, and preventing cardiovascular events, with the most recent and highest quality guideline recommendations provided by the 2020 KDIGO clinical practice guideline for diabetes management in CKD 1.

Key Recommendations

• Lifestyle modifications including a low-sodium diet (less than 2g daily), moderate protein restriction (0.8g/kg/day), smoking cessation, regular exercise, and weight management.
• Blood pressure control is crucial, targeting below 130/80 mmHg, primarily using ACE inhibitors (like enalapril 5-40mg daily) or ARBs (such as losartan 25-100mg daily) which provide renoprotection beyond blood pressure control, as recommended by the 2013 KDIGO guideline summary 1.
• For diabetic patients, glycemic control is essential with a target HbA1c of 7-8%, using medications like SGLT2 inhibitors (empagliflozin 10-25mg daily or dapagliflozin 5-10mg daily) which have demonstrated kidney and cardiovascular benefits.
• Statins are recommended for lipid management regardless of baseline cholesterol levels.
• As CKD progresses, additional treatments include phosphate binders (calcium acetate, sevelamer) for hyperphosphatemia, vitamin D supplements (calcitriol 0.25-1mcg daily) for secondary hyperparathyroidism, and erythropoiesis-stimulating agents (darbepoetin alfa 0.45mcg/kg weekly) for anemia when hemoglobin falls below 10g/dL.
• Metabolic acidosis should be corrected with sodium bicarbonate (500-1000mg three times daily) when serum bicarbonate is below 22mEq/L.
• Regular monitoring of kidney function, electrolytes, and complications is essential, with referral to nephrology typically recommended when eGFR falls below 30ml/min/1.73m², as suggested by the 2003 Renal Physicians Association clinical practice guideline 1.
• For end-stage kidney disease, preparation for renal replacement therapy (dialysis or transplantation) should begin when eGFR approaches 20ml/min/1.73m².

Implementation

The 2014 KDOQI US commentary on the 2012 KDIGO clinical practice guideline for the evaluation and management of CKD suggests approaching the recommendations with flexibility to identify aspects of the guideline that may be more applicable to individual patients with CKD and to modify treatment strategies over the course of care 1. The guideline also acknowledges that evidence is strongest for recommendations related to management of diabetes and hypertension, which often complicate CKD. Thus, it would be justifiable to first devote effort to setting blood pressure and glycemic goals, tailor antihypertensive and hypoglycemic therapies to individual patients, and monitor for side effects of the medications. Reduction in dietary sodium may facilitate achievement of blood pressure goals and the widespread use of sodium in the US food supply.

Monitoring and Referral

Regular monitoring of kidney function, electrolytes, and complications is essential, with referral to nephrology typically recommended when eGFR falls below 30ml/min/1.73m². For end-stage kidney disease, preparation for renal replacement therapy (dialysis or transplantation) should begin when eGFR approaches 20ml/min/1.73m².

From the FDA Drug Label

For all patients with CKD: When initiating or adjusting therapy, monitor hemoglobin levels at least weekly until stable, then monitor at least monthly When adjusting therapy consider hemoglobin rate of rise, rate of decline, ESA responsiveness and hemoglobin variability. A single hemoglobin excursion may not require a dosing change. Do not increase the dose more frequently than once every 4 weeks. Decreases in dose can occur more frequently. Avoid frequent dose adjustments. If the hemoglobin rises rapidly (e.g., more than 1 g/dL in any 2-week period), reduce the dose of PROCRIT by 25% or more as needed to reduce rapid responses. For patients who do not respond adequately, if the hemoglobin has not increased by more than 1 g/dL after 4 weeks of therapy, increase the dose by 25% For patients who do not respond adequately over a 12-week escalation period, increasing the PROCRIT dose further is unlikely to improve response and may increase risks. Use the lowest dose that will maintain a hemoglobin level sufficient to reduce the need for RBC transfusions. Evaluate other causes of anemia. Discontinue PROCRIT if responsiveness does not improve

The treatment guidelines for Chronic Kidney Disease (CKD) include:

• Initiating epoetin alfa treatment when the hemoglobin level is less than 10 g/dL
• Monitoring hemoglobin levels at least weekly until stable, then at least monthly
• Adjusting the dose based on hemoglobin rate of rise, rate of decline, ESA responsiveness, and hemoglobin variability
• Using the lowest dose of epoetin alfa sufficient to reduce the need for RBC transfusions
• Evaluating other causes of anemia and discontinuing epoetin alfa if responsiveness does not improve 2

From the Research

Treatment Guidelines for Chronic Kidney Disease (CKD)

The treatment guidelines for CKD involve a combination of lifestyle modifications, nutritional interventions, and therapeutic interventions. The following are some of the key recommendations:

• Lifestyle modifications:
  • Walking and physical activity to slow the progression of CKD 3
  • Weight loss to reduce the risk of CKD progression 3, 4
  • Smoking cessation to prevent CKD progression 3, 4
  • Limiting alcohol consumption to reduce the risk of CKD progression 3, 4
• Nutritional interventions:
  • Low-protein diet (LPD) to slow the progression of CKD 3
  • Adherence to the alternate Mediterranean (aMed) diet to slow the progression of CKD 3
  • Alternative Healthy Eating Index (AHEI)-2010 to slow the progression of CKD 3
  • Reducing sodium intake to control blood pressure and slow CKD progression 5
• Therapeutic interventions:
  • Blood pressure control: <140/90 mmHg in patients without albuminuria and <130/80 mmHg in patients with albuminuria to prevent CKD progression 3, 6
  • Glycemic control in diabetic patients to slow CKD progression 3, 6
  • Reduce proteinuria to slow CKD progression 3, 6
  • Medications: RAAS blockade, sodium-glucose cotransporter-2 (SGLT2) inhibitors, pentoxifylline, and finerenone to manage CKD 3
  • Atrasentan, an endothelin receptor antagonist (ERA), to decrease the risk of renal events in diabetic CKD patients 3

Management of CKD

The management of CKD requires a multidisciplinary approach, involving early detection and management of CKD, and a combination of lifestyle modifications, nutritional interventions, and therapeutic interventions. The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommend regular monitoring of kidney function and referral to a nephrologist for patients with advanced CKD or other complications 6.

Safety of Therapies

The safety of ACE inhibitor therapies in patients with CKD is a concern, with potential adverse effects including hypotension, renal function impairment, and hyperkalemia 5. Dual RAAS-blockade is no longer advocated in patients with CKD due to safety issues, and combination of ACE inhibitors with moderate reduction in dietary sodium intake is a better alternative 5.

Adherence to Nutritional Advice

Poor adherence to diet, medications, and treatments is a significant concern in patients with CKD, and can contribute to increased mortality and morbidity 7. Strategies to promote adherence to nutritional advice include individualized education and counseling, integrating patient-owned technology, and involving the total patient food environment 7.