What is the recommended cycle of care for patients with chronic kidney disease?

From the Guidelines

The recommended cycle of care for patients with chronic kidney disease (CKD) should include a comprehensive strategy to reduce risks of kidney disease progression and cardiovascular disease, as outlined in the most recent guidelines 1. This care cycle should include regular monitoring every 3-6 months for stable patients and more frequently for those with advanced disease. The monitoring should comprise measurement of kidney function through estimated glomerular filtration rate (eGFR) and urine albumin-to-creatinine ratio (UACR), blood pressure monitoring targeting levels below 130/80 mmHg, and comprehensive metabolic panels to assess electrolytes, particularly potassium and phosphorus. Medication management is essential, typically including ACE inhibitors or ARBs (such as lisinopril 10-40 mg daily or losartan 25-100 mg daily) to control blood pressure and reduce proteinuria, as well as the use of SGLT2 inhibitors and GLP-1 RAs for patients with diabetic kidney disease, as supported by recent trials 1. Patients should have regular screening for complications including anemia (hemoglobin), bone mineral disorders (calcium, phosphorus, vitamin D, PTH), and metabolic acidosis (bicarbonate levels). Nutritional counseling should address sodium restriction (less than 2 grams daily), protein modification (0.8 g/kg/day for stages 1-4, potentially lower for stage 5), and potassium and phosphorus limitations as needed. Annual screening for cardiovascular disease is important as CKD patients have elevated cardiovascular risk. This comprehensive approach helps slow CKD progression by addressing the underlying pathophysiology of kidney damage, including glomerular hypertension, proteinuria, and metabolic derangements that can accelerate kidney function decline. Additionally, referral to a specialist, such as a nephrologist, is recommended for patients with a GFR less than 30 mL/min per 1.73 m^2, to facilitate timely preparation for kidney replacement therapy and improve outcomes 1. The delivery of health care by a multidisciplinary team affords the potential to achieve truly integrated care for patients with CKD, particularly those with diabetic kidney disease 1. By following this cycle of care, patients with CKD can receive optimal management of their disease, reducing the risk of progression and cardiovascular complications. Key aspects of the care cycle include:

• Regular monitoring of kidney function and cardiovascular risk factors
• Medication management with ACE inhibitors, ARBs, SGLT2 inhibitors, and GLP-1 RAs as appropriate
• Nutritional counseling and lifestyle modifications
• Screening for complications and referral to specialists as needed
• Multidisciplinary care to achieve integrated management of CKD and its comorbidities.

From the Research

Chronic Kidney Disease Cycle of Care

The management of chronic kidney disease (CKD) involves a comprehensive cycle of care that includes screening, monitoring, and treatment. The following are key components of the CKD cycle of care:

• Screening for CKD using estimated glomerular filtration rate (eGFR) and urine albumin-to-creatinine ratio (UACR) 2
• Monitoring of serum creatinine and UACR to assess disease progression 3
• Treatment with sodium-glucose co-transporter 2 (SGLT2) inhibitors, angiotensin-converting enzyme (ACE) inhibitors, or angiotensin receptor blockers (ARBs) to slow disease progression and reduce cardiovascular risk 4, 5
• Referral to nephrology care for patients with advanced CKD or those who require specialized management 6

Key Considerations

The CKD cycle of care should be individualized based on patient characteristics, such as diabetes status, eGFR, and UACR. The following are key considerations:

• Albuminuria testing should be performed regularly to assess renal damage and guide treatment decisions 6
• SGLT2 inhibitors have been shown to reduce the risk of CKD progression and cardiovascular events in patients with CKD, regardless of diabetes status 4, 5
• ACE inhibitors or ARBs should be used to slow CKD progression and reduce proteinuria 3
• Patients with CKD should be monitored regularly for complications, such as cardiovascular disease, anemia, and bone disease 3

Gaps in Care

Despite the availability of guidelines and evidence-based treatments, there are gaps in the care of patients with CKD. The following are key gaps:

• Underutilization of albuminuria testing, which can lead to delayed diagnosis and treatment of CKD 6
• Inadequate monitoring of serum creatinine and UACR, which can lead to delayed recognition of disease progression 3
• Limited use of SGLT2 inhibitors and other evidence-based treatments, which can lead to poor outcomes 4, 5
• Inequitable access to nephrology care, which can lead to disparities in outcomes 6