What is the management approach for patients with Chronic Kidney Disease (CKD)?

Management Approach for Chronic Kidney Disease (CKD)

The management of chronic kidney disease requires a comprehensive approach targeting blood pressure control, cardiovascular risk reduction, lifestyle modifications, and prevention of disease progression, with specific interventions tailored to CKD stage and albuminuria level.

Blood Pressure Management

Blood pressure control is critical in preventing CKD progression:

• Target blood pressure: <120 mmHg systolic when tolerated, using standardized office BP measurement 1
• For patients with albuminuria ≥30 mg/24 hours, maintain BP ≤130/80 mmHg 1
• For patients with albuminuria <30 mg/24 hours, maintain BP ≤140/90 mmHg 1

Antihypertensive Therapy:

1. First-line agents:

   • ACE inhibitors or ARBs are recommended first-line for patients with albuminuria >300 mg/24 hours 1
   • These medications slow progression of both diabetic and non-diabetic nephropathy by reducing proteinuria 1

2. Additional agents as needed:

   • Diuretics (cornerstone in CKD management, especially with volume overload)
   • Calcium channel blockers (non-dihydropyridine CCBs reduce albuminuria)
   • Beta-blockers (particularly in patients with heart failure or coronary disease)

Pitfall: Avoid combining ACE inhibitors with ARBs due to increased risk of hyperkalemia and acute kidney injury without additional benefit.

Cardiovascular Risk Reduction

CKD patients are more likely to die from cardiovascular disease than progress to end-stage kidney disease 1:

• Statin therapy:

  • Adults ≥50 years with eGFR <60 ml/min/1.73m²: statin or statin/ezetimibe combination 1
  • Adults ≥50 years with eGFR ≥60 ml/min/1.73m²: statin therapy 1
  • Adults 18-49 years with CKD: statin if they have coronary disease, diabetes, prior stroke, or 10-year CV risk >10% 1

• Antiplatelet therapy:

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

• Atrial fibrillation management:

  • Use NOACs in preference to warfarin for thromboprophylaxis in CKD G1-G4 1
  • Dose adjustment required based on GFR 1

Lifestyle Modifications

• Physical activity: At least 150 minutes per week of moderate-intensity activity 1
• Diet:
  • Sodium restriction <2 g/day 1
  • Plant-based "Mediterranean-style" diet 1
  • 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
• Weight management: Achieve healthy BMI (20-25 kg/m²) 1
• Smoking cessation 1

Management of CKD Complications

Hyperkalemia

• Individualized approach including dietary and pharmacologic interventions 1
• Limit intake of foods rich in bioavailable potassium 1

Hyperuricemia and Gout

• Treat symptomatic hyperuricemia with uric acid-lowering therapy 1
• For acute gout, use low-dose colchicine or glucocorticoids rather than NSAIDs 1
• Do not treat asymptomatic hyperuricemia to delay CKD progression 1

Metabolic Acidosis

• Monitor and treat metabolic acidosis to slow CKD progression
• Consider oral bicarbonate supplementation

Anemia

• Evaluate and treat iron deficiency
• Consider erythropoiesis-stimulating agents when appropriate

Monitoring and Follow-up

Frequency of monitoring should be based on GFR and albuminuria categories:

• Higher risk patients (lower GFR, higher albuminuria) require more frequent monitoring 1
• Monitor for disease progression (defined as change in GFR category confirmed by ≥25% change in eGFR) 1

Prevention of Acute Kidney Injury

• All CKD patients should be considered at increased risk for AKI 1
• Avoid nephrotoxins when possible (NSAIDs, certain antibiotics)
• Ensure adequate hydration during procedures requiring contrast agents

Special Considerations

Coronary Artery Disease

• In stable ischemic heart disease, an initial conservative approach using intensive medical therapy is appropriate 1
• Invasive strategy may be preferable for unstable coronary disease, unacceptable angina, LV dysfunction, or left main disease 1

Diabetes Management

• Target HbA1c of approximately 7% 1
• Consider SGLT2 inhibitors for their renoprotective effects

Important caveat: CKD patients should receive the same level of care for ischemic heart disease as those without CKD, without prejudice due to their kidney disease 1.