What are the recommendations for Chronic Kidney Disease (CKD) management?

Comprehensive Management of Chronic Kidney Disease (CKD)

The management of chronic kidney disease requires a comprehensive treatment strategy that addresses lifestyle modifications, blood pressure control, glycemic management, cardiovascular risk reduction, and specific pharmacological interventions to reduce the risk of CKD progression and associated complications. 1

Core Management Strategies

Lifestyle Modifications

Physical Activity

• Recommendation: Moderate-intensity physical activity for at least 150 minutes per week 1
  • Adjust intensity based on cardiovascular tolerance and frailty level
  • For patients at high fall risk: Provide specific guidance on exercise intensity (low/moderate/vigorous) and type (aerobic vs. resistance)
  • For children: Aim for WHO-advised levels (≥60 minutes daily) 1

Diet

• Plant-based approach:

  • Higher consumption of plant-based foods compared to animal-based foods 1
  • Lower consumption of ultraprocessed foods
  • Consider a "Mediterranean-style" diet to reduce cardiovascular risk 1

• Protein intake:

  • Maintain protein intake of 0.8 g/kg body weight/day in adults with CKD G3-G5 1
  • Avoid high protein intake (>1.3 g/kg/day) in adults with CKD at risk of progression 1
  • For patients at risk of kidney failure: Consider very low-protein diet (0.3-0.4 g/kg/day) with amino acid or ketoacid supplements 1
  • Caution: Do not restrict protein in children with CKD or metabolically unstable patients 1
  • For older adults with frailty/sarcopenia: Consider higher protein targets 1

• Sodium intake:

  • Limit to <2 g sodium per day (<5 g sodium chloride) 1
  • Exception: Not appropriate for patients with sodium-wasting nephropathy 1

• Potassium management:

  • Limit intake of foods rich in bioavailable potassium (e.g., processed foods) for CKD G3-G5 patients with history of hyperkalemia 1
  • Individualize approach for emergent hyperkalemia, including dietary and pharmacologic interventions 1

Weight Management

• Encourage weight loss for patients with obesity and CKD 1
• Aim for optimal BMI (20-25 kg/m²) 1

Tobacco and Alcohol

• Advise complete cessation of tobacco products 1
• Limit alcohol consumption to prevent gout and CKD progression 1

Blood Pressure Management

• Target blood pressure:
  • For adults with CKD: <120 mmHg systolic when tolerated 1

Lipid Management

• Statin therapy:
  • Adults ≥50 years with eGFR <60 ml/min/1.73 m²: Statin or statin/ezetimibe combination 1
  • Adults ≥50 years with eGFR ≥60 ml/min/1.73 m²: Statin therapy 1
  • Adults 18-49 years: Consider statin if they have coronary disease, diabetes, prior ischemic stroke, or 10-year cardiovascular risk >10% 1
  • Choose statin regimens that maximize LDL cholesterol reduction 1
  • Consider PCSK-9 inhibitors when indicated 1

Management of Hyperuricemia and Gout

• For symptomatic hyperuricemia:

  • Offer uric acid-lowering therapy 1
  • Consider initiating therapy after first gout episode, especially with serum uric acid >9 mg/dl 1
  • Prefer xanthine oxidase inhibitors over uricosuric agents 1

• For acute gout in CKD:

  • Use low-dose colchicine or intra-articular/oral glucocorticoids instead of NSAIDs 1

• For asymptomatic hyperuricemia:

  • Do not use uric acid-lowering agents to delay CKD progression 1

• Dietary approaches for gout prevention:

  • Limit alcohol, meats, and high-fructose corn syrup intake 1

Cardiovascular Risk Management

• Antiplatelet therapy:

  • Low-dose aspirin for secondary prevention in patients with established ischemic cardiovascular disease 1
  • Consider P2Y12 inhibitors when aspirin is not tolerated 1

• Coronary artery disease approach:

  • For stable ischemic heart disease: Initial conservative approach with intensive medical therapy is appropriate 1
  • For acute/unstable coronary disease: Consider initial invasive strategy 1

Special Considerations

Pediatric Patients

• Do not restrict protein intake in children with CKD 1
• Target protein and energy intake at upper end of normal range for healthy children 1
• Encourage physical activity (≥60 minutes daily) 1

Older Adults

• For frailty and sarcopenia: Consider higher protein and calorie targets 1
• Adjust physical activity recommendations based on fall risk 1

Implementation Strategy

1. Assessment:

   • Evaluate CKD stage, albuminuria, comorbidities
   • Assess cardiovascular risk using validated tools 1
   • Screen for hyperkalemia, hyperuricemia, dyslipidemia

2. Education:

   • Refer to renal dietitians for individualized nutritional guidance 1
   • Provide specific dietary adaptations for sodium, phosphorus, potassium, and protein 1

3. Monitoring:

   • Regular assessment of kidney function
   • Monitor for hyperkalemia, especially when using RAAS inhibitors
   • Track cardiovascular risk factors

Common Pitfalls and Caveats

• Protein restriction: Avoid in children and metabolically unstable patients 1
• Sodium restriction: Not appropriate for sodium-wasting nephropathy 1
• Uric acid-lowering therapy: Only for symptomatic hyperuricemia, not for asymptomatic cases 1
• Cardiovascular care: Do not prejudice level of care based on CKD status 1
• Medication adjustments: Consider dose modifications for medications cleared by the kidneys

By implementing this comprehensive approach to CKD management, focusing on lifestyle modifications, appropriate pharmacotherapy, and regular monitoring, the progression of CKD can be delayed and associated complications can be reduced, ultimately improving patient outcomes and quality of life.