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

Comprehensive Management Strategies for Chronic Kidney Disease (CKD)

The management of chronic kidney disease requires a holistic approach focusing on lifestyle modifications, pharmacological interventions, and regular monitoring to reduce the risk of disease progression and cardiovascular complications. 1

Core Treatment Strategy

The KDIGO 2024 guidelines recommend a comprehensive treatment strategy that addresses multiple aspects of CKD management:

Lifestyle Modifications

• Physical Activity:

  • Moderate-intensity physical activity for at least 150 minutes per week, adjusted to individual cardiovascular and physical tolerance 1
  • Avoid sedentary behavior 1
  • For fall-risk patients, tailor exercise intensity (low, moderate, or vigorous) and type (aerobic vs. resistance) 1

• Diet:

  • Adopt healthy, diverse diets with higher consumption of plant-based foods compared to animal-based foods 1
  • Reduce consumption of ultra-processed foods 1
  • Maintain protein intake of 0.8 g/kg body weight/day for adults with CKD G3-G5 1
  • Avoid high protein intake (>1.3 g/kg/day) in adults at risk of CKD progression 1
  • Limit sodium intake to <2000 mg/day 1
  • Consult with renal dietitians for individualized dietary adaptations regarding sodium, phosphorus, potassium, and protein 1

• Weight Management:

  • Achieve and maintain optimal body mass index (BMI) 1
  • Weight loss is recommended for patients with obesity and CKD 1

• Smoking Cessation:

  • Complete avoidance of tobacco products 1

Blood Pressure Control

• For patients with albuminuria ≥30 mg/24 hours: target BP ≤130/80 mmHg 1
• For patients with albuminuria <30 mg/24 hours: target BP ≤140/90 mmHg 1
• Use ACE inhibitors or ARBs as first-line therapy for patients with albuminuria >300 mg/24 hours 1

Glycemic Control in Diabetic CKD

• Target HbA1c of approximately 7% 1
• Implement a comprehensive approach including:
  • Metformin (when eGFR ≥30 ml/min/1.73 m²) 1
  • SGLT2 inhibitors (initiate when eGFR ≥20 ml/min/1.73 m², continue until dialysis or transplantation) 1
  • GLP-1 receptor agonists for patients with T2D when additional glycemic control is needed 1

Cardiovascular Risk Reduction

• Statin therapy for all patients with diabetes and CKD 1
• Consider antiplatelet therapy for established cardiovascular disease 1
• Apply the same principles to diagnose and manage atherosclerotic cardiovascular disease and atrial fibrillation as in people without CKD 1

Monitoring and Risk Assessment

Regular Assessment

• Monitor kidney function and albuminuria regularly (every 3-6 months) 1
• Use validated risk prediction equations to estimate kidney failure risk 1
  • 5-year kidney failure risk of 3%-5% indicates need for nephrology referral 1
  • 2-year kidney failure risk >10% indicates timing for multidisciplinary care 1
  • 2-year kidney failure risk >40% indicates need for kidney replacement therapy preparation 1

Management of CKD Complications

• Monitor and treat laboratory abnormalities associated with CKD:
  • Anemia
  • CKD-mineral and bone disorders (CKD-MBD)
  • Potassium disorders
  • Metabolic acidosis 1

Special Considerations

Multidisciplinary Care

• Implement multidisciplinary care models to overcome barriers to effective management 1
• Include diabetes care specialists, physicians, nurses, dietitians, pharmacists, and other healthcare professionals 1

Acute Kidney Injury (AKI) Prevention

• All people with CKD should be considered at increased risk of AKI 1
• Avoid nephrotoxins when possible 2

Pediatric Considerations

• Children with CKD should undertake physical activity aiming for WHO-advised levels (≥60 minutes daily) 1
• Achieve and maintain healthy weight 1

Common Pitfalls and Caveats

1. Underrecognition: Less than 5% of patients with early CKD report awareness of their disease, leading to delayed intervention 2

2. Medication Dosing: Failure to adjust medication dosages for reduced kidney function can lead to adverse effects 2

3. Nephrotoxin Exposure: Continued use of potentially nephrotoxic medications like NSAIDs can accelerate CKD progression 2

4. Inadequate Risk Assessment: Not using validated risk prediction tools may lead to delayed referral to nephrology care 1

5. Focusing on Single Interventions: The most effective approach is comprehensive, addressing multiple risk factors simultaneously rather than focusing on single interventions 1

By implementing this comprehensive management strategy, healthcare providers can effectively reduce the risk of CKD progression, minimize complications, and improve quality of life for patients with chronic kidney disease.