Management Strategies for Different Stages of Chronic Kidney Disease (CKD)
Management of CKD should follow a stage-specific approach that addresses both the underlying kidney disease and its complications to reduce morbidity and mortality. 1
CKD Definition and Staging
CKD is defined as kidney damage or glomerular filtration rate (GFR) <60 mL/min/1.73 m² persisting for at least 3 months. The staging system is based on GFR levels:
| Stage | Description | GFR (mL/min/1.73 m²) |
|---|---|---|
| 1 | Kidney damage with normal or increased GFR | ≥90 |
| 2 | Kidney damage with mild decrease in GFR | 60-89 |
| 3 | Moderate decrease in GFR | 30-59 |
| 4 | Severe decrease in GFR | 15-29 |
| 5 | Kidney failure | <15 or dialysis |
Stage-Specific Management Strategies
Stage 1 and 2 CKD
- Primary focus: Screening, diagnosis, and CKD risk reduction 1
- Key interventions:
- Identify and treat underlying causes (diabetes, hypertension)
- Blood pressure control (<140/90 mmHg)
- Glycemic control in diabetic patients
- Cardiovascular disease risk reduction
- ACE inhibitors or ARBs for albuminuria
- Avoid nephrotoxins (NSAIDs)
- Monitor GFR and albuminuria every 12 months 1
Stage 3 CKD
- Primary focus: Slowing progression and managing complications 1
- Key interventions:
- Continue all Stage 1-2 interventions
- Monitor GFR and albuminuria every 6 months
- Evaluate for anemia (hemoglobin levels)
- Monitor serum bicarbonate every 3 months 1
- Correct metabolic acidosis to serum bicarbonate ≥22 mmol/L 1
- Monitor calcium, phosphorus every 3 months, and iPTH at least once 1
- Evaluate and control dyslipidemia with statins 1
- Consider SGLT2 inhibitors even in non-diabetic patients 2
Stage 4 CKD
- Primary focus: Evaluating and treating complications, preparing for kidney replacement therapy 1
- Key interventions:
- Continue all previous stage interventions
- Monitor GFR and albuminuria every 3 months
- Manage mineral bone disorders (calcium, phosphorus, PTH) 1
- Manage anemia with erythropoiesis-stimulating agents as needed
- Monitor BP with each erythropoietin dose 1
- Nutritional counseling (protein, phosphorus, potassium restrictions)
- Prepare for kidney replacement therapy (dialysis access planning, transplant evaluation)
- Vaccination updates (hepatitis B, pneumococcal, influenza)
Stage 5 CKD
- Primary focus: Kidney replacement therapy or conservative management 1
- Key interventions:
- Initiate dialysis when clinically indicated (uremic symptoms)
- Manage dialysis adequacy if on dialysis
- Continue management of all complications
- Kidney transplant evaluation and listing if appropriate
- Palliative care discussions for those choosing conservative management
Management of Common Complications
Hypertension
- Prevalence approaches 80% in Stage 4 CKD 1
- Target BP <140/90 mmHg for most patients
- ACE inhibitors or ARBs are preferred agents, especially with albuminuria
- Dose adjustment required as GFR declines
Anemia
- Monitor hemoglobin regularly, especially when GFR <60 mL/min/1.73 m² 1
- Evaluate iron status before initiating treatment
- Consider erythropoiesis-stimulating agents when appropriate
Metabolic Acidosis
- Monitor serum bicarbonate every 3 months when GFR <30 mL/min/1.73 m² 1
- Correct to ≥22 mmol/L with oral bicarbonate supplementation
Mineral Bone Disorders
- Monitor calcium, phosphorus every 3 months in Stage 4-5 CKD 1
- Monitor PTH every 6-12 months in Stage 4 and every 3-6 months in Stage 5 1
- Phosphate binders for hyperphosphatemia
- Vitamin D analogs for secondary hyperparathyroidism
Cardiovascular Disease
- Major cause of morbidity and mortality in CKD 3
- Statin therapy for dyslipidemia
- Aspirin for secondary prevention
- Manage heart failure with appropriate medications
Medication Adjustments in CKD
Several medications require dose adjustment or avoidance in advanced CKD:
- Metformin: Contraindicated when eGFR <30 mL/min/1.73 m², use with caution and reduced dose when eGFR 30-45 mL/min/1.73 m² 1
- Sulfonylureas: Avoid glyburide in advanced CKD; use glipizide or glimepiride with caution 1
- SGLT2 inhibitors: Beneficial for cardiorenal protection but efficacy for glucose lowering decreases with declining GFR 2
- Antibiotics: Many require dose adjustment based on GFR
Monitoring Frequency
| Parameter | Stage 3 | Stage 4 | Stage 5 |
|---|---|---|---|
| GFR | Every 6 months | Every 3 months | Monthly |
| Albuminuria | Every 6 months | Every 3 months | Monthly |
| Hemoglobin | Every 6 months | Every 3 months | Monthly |
| Calcium/Phosphorus | Every 6 months | Every 3 months | Monthly |
| PTH | Annually | Every 6-12 months | Every 3-6 months |
| Bicarbonate | Every 3 months | Every 3 months | Monthly |
Clinical Pitfalls to Avoid
Relying solely on serum creatinine: Can lead to overestimation of kidney function, especially in elderly or malnourished patients 1
Delayed diagnosis: Associated with increased risk of progression to advanced CKD and adverse cardiovascular outcomes 4
Nephrotoxic medications: NSAIDs, certain antibiotics, and contrast agents can worsen kidney function
Inadequate monitoring: Failure to detect and manage complications like anemia, mineral bone disorders, and acidosis
Late referral to nephrology: Patients with rapid GFR decline, GFR <30 mL/min/1.73 m², or severe albuminuria should be promptly referred 5