What medications are recommended for patients with Chronic Kidney Disease (CKD)?

Medication Management for Chronic Kidney Disease

For patients with chronic kidney disease (CKD), first-line medications should include renin-angiotensin system inhibitors (ACEi or ARB) and SGLT2 inhibitors, with additional medications selected based on comorbidities and CKD stage. 1

Core Medication Strategy

First-Line Medications

1. Renin-Angiotensin System Inhibitors (RASi)

   • ACE inhibitors or ARBs are strongly recommended for:
     • Patients with CKD and severely increased albuminuria (G1-G4, A3) without diabetes (1B) 1
     • Patients with CKD and moderately increased albuminuria (G1-G4, A2) without diabetes (2C) 1
     • Patients with CKD and moderately-to-severely increased albuminuria (G1-G4, A2 and A3) with diabetes (1B) 1
   • Dosing considerations:
     • Use highest approved dose that is tolerated 1
     • Monitor serum creatinine and potassium within 2-4 weeks of initiation or dose increase 1
     • Continue therapy unless serum creatinine rises >30% within 4 weeks 1
     • Continue even when eGFR falls below 30 ml/min per 1.73 m² 1

2. SGLT2 Inhibitors

   • Recommended for patients with type 2 diabetes, CKD, and eGFR ≥20 ml/min per 1.73 m² (1A) 1
   • Benefits include slowing CKD progression and reducing cardiovascular events 1

Additional Medications Based on Comorbidities

1. Hypertension Management

   • Target blood pressure: <120 mm Hg systolic when tolerated (2B) 1
   • First-line options for black patients: Thiazide-type diuretic or calcium channel blocker 1
   • First-line options for non-black patients: ACEi, ARB, thiazide-type diuretic, or calcium channel blocker 1
   • Consider less intensive BP targets in frail patients, those with fall risk, limited life expectancy, or postural hypotension 1

2. Lipid Management

   • Statins recommended for:
     • Adults ≥50 years with eGFR <60 ml/min per 1.73 m² (1A) 1
     • Adults ≥50 years with CKD and eGFR ≥60 ml/min per 1.73 m² (1B) 1
     • Adults 18-49 years with coronary disease, diabetes, prior stroke, or high cardiovascular risk (2A) 1
   • Statin dosing in CKD: Most statins don't require dose adjustment in mild-moderate CKD 1

3. Diabetes Management

   • GLP-1 RAs: Effective regardless of kidney function, with low hypoglycemia risk 1
   • Metformin: Preferred agent but reduce dose when eGFR <45 ml/min/1.73 m² and stop when <30 ml/min/1.73 m² 1

Special Considerations

Medication Safety in CKD

1. Hyperkalemia Management with RASi

   • Hyperkalemia can often be managed without stopping RASi 1
   • Options include:
     • Dietary potassium restriction
     • Diuretics
     • Sodium bicarbonate
     • GI cation exchangers
   • Consider dose reduction or discontinuation only if hyperkalemia is uncontrolled despite treatment 1

2. Drug Interactions

   • NSAIDs: May worsen kidney function and reduce antihypertensive effects of RASi 2
   • Dual RAS blockade: Avoid combination of ACEi, ARB, and direct renin inhibitors (1B) 1
   • Lithium: Monitor levels when used with ARBs due to risk of lithium toxicity 2

CKD Stage-Specific Considerations

1. Early CKD (Stages 1-3)

   • Full doses of most medications can be used
   • Focus on preventing progression and cardiovascular events

2. Advanced CKD (Stages 4-5)

   • Medication adjustments often needed
   • Consider reducing or discontinuing ACEi/ARB in:
     • Symptomatic hypotension
     • Uncontrolled hyperkalemia
     • Uremic symptoms in kidney failure (eGFR <15 ml/min per 1.73 m²) 1

3. Sodium Restriction

   • Recommend <2g sodium per day (<5g sodium chloride) for most CKD patients (2C) 1
   • Exception: Not appropriate for patients with sodium-wasting nephropathy 1

Practical Implementation Algorithm

1. Initial Assessment

   • Determine CKD stage (eGFR and albuminuria)
   • Assess comorbidities (diabetes, hypertension, cardiovascular disease)
   • Check baseline labs (creatinine, potassium, lipids)

2. Medication Selection

   • For all CKD patients with albuminuria: Start RASi (ACEi or ARB)
   • For type 2 diabetes with CKD: Add SGLT2i if eGFR ≥20 ml/min/1.73 m²
   • For hypertension: Add thiazide diuretic, calcium channel blocker, or other agents as needed
   • For cardiovascular risk: Add statin therapy

3. Monitoring

   • Check creatinine and potassium 2-4 weeks after starting or increasing RASi
   • Monitor blood pressure regularly
   • Assess for medication side effects and interactions

Common Pitfalls to Avoid

1. Inappropriate discontinuation of RASi due to mild, expected increases in creatinine

   • Continue unless creatinine rises >30% within 4 weeks 1

2. Failure to adjust medication doses in advanced CKD

   • Many medications require dose adjustment or discontinuation as kidney function declines

3. Overlooking non-pharmacological interventions

   • Dietary sodium restriction, exercise, and smoking cessation are essential components of CKD management 1

4. Dual RAS blockade

   • Avoid combining ACEi, ARB, or direct renin inhibitors due to increased risk of adverse effects without additional benefit 1

5. Underutilization of SGLT2 inhibitors

   • These agents provide significant cardiorenal protection and should be considered for eligible patients 3

By implementing this evidence-based medication approach, clinicians can effectively manage CKD to reduce the risk of disease progression, cardiovascular events, and mortality while maintaining quality of life.