What is the management of Chronic Kidney Disease (CKD)?

Management of Chronic Kidney Disease (CKD)

The comprehensive management of CKD requires a multidisciplinary approach focused on lifestyle modifications, blood pressure control, use of renin-angiotensin system inhibitors, SGLT2 inhibitors, lipid management, and treatment of specific complications to reduce mortality and improve quality of life.

Classification and Monitoring

CKD is defined as persistent abnormalities in kidney structure or function for >3 months, characterized by:

• GFR <60 mL/min/1.73 m² and/or
• Albuminuria ≥30 mg/24 hours

The frequency of monitoring depends on CKD severity:

• Low risk (G1-G2 with A1): Annual monitoring
• Moderate risk (G3a with A1 or G1-G2 with A2): 1-2 times per year
• High risk (G4-G5 or any category with A3): 3-4 times per year 1

Core Management Strategies

1. Blood Pressure Control

• For patients with albuminuria <30 mg/24 hours: Target BP ≤140/90 mmHg 2
• For patients with albuminuria ≥30 mg/24 hours: Target BP ≤130/80 mmHg 2
• First-line agents:
  • ACE inhibitors or ARBs are strongly recommended for patients with albuminuria >300 mg/24 hours 2
  • Add dihydropyridine calcium channel blockers and/or diuretics if needed to achieve BP targets 2

2. Management of Diabetes in CKD

• First-line medications:
  • SGLT2 inhibitors: Initiate when eGFR ≥20 mL/min/1.73 m² and continue until dialysis or transplantation 2
  • Metformin: Use when eGFR ≥30 mL/min/1.73 m² 2
  • GLP-1 receptor agonists: Consider when additional glycemic control is needed 2

3. Lipid Management

• For adults ≥50 years with eGFR <60 mL/min/1.73 m²: Statin or statin/ezetimibe combination 2
• For adults ≥50 years with eGFR ≥60 mL/min/1.73 m²: Statin therapy 2
• For adults 18-49 years: Consider statin therapy if they have coronary disease, diabetes, prior ischemic stroke, or 10-year cardiovascular risk >10% 2
• Consider PCSK9 inhibitors for patients with indications for their use 2

4. Lifestyle Modifications

• Diet:

  • Plant-based "Mediterranean-style" diet 2, 1
  • Sodium restriction to <2000 mg/day 1
  • Protein intake of 0.8 g/kg body weight/day for adults with CKD G3-G5 1
  • Limit foods rich in bioavailable potassium for patients with history of hyperkalemia 2

• Physical Activity:

  • Moderate-intensity physical activity for at least 150 minutes per week 1
  • Adjust intensity based on individual cardiovascular tolerance and fall risk 1

• Other Lifestyle Factors:

  • Complete smoking cessation 2, 1
  • Weight management: achieve and maintain optimal BMI 1
  • Limit alcohol consumption 3

Management of Specific Complications

1. Hyperkalemia

• Individualized approach including dietary and pharmacologic interventions 2
• Limit intake of foods rich in bioavailable potassium (especially processed foods) 2
• Consider potassium exchange agents based on local availability 2

2. Hyperuricemia

• For symptomatic hyperuricemia/gout: Uric acid-lowering therapy 2
  • Prefer xanthine oxidase inhibitors over uricosuric agents 2
  • For acute gout: Low-dose colchicine or glucocorticoids rather than NSAIDs 2
• For asymptomatic hyperuricemia: Uric acid-lowering agents not recommended to delay CKD progression 2

3. Cardiovascular Risk

• Low-dose aspirin for secondary prevention in patients with established ischemic cardiovascular disease 2
• Ensure that CKD status does not prejudice the level of care for ischemic heart disease 2

4. Mineral and Bone Disorders

• Treat metabolic acidosis when bicarbonate <18 mmol/L 1
• Manage anemia according to KDIGO guidelines 1

Multidisciplinary Care Approach

A team-based approach is essential, including:

• Nephrologist
• Primary care physician
• Endocrinologist (for diabetic patients)
• Dietitian
• Pharmacist
• Nurse
• Cardiologist (when needed) 2, 1

Referral to Nephrology

Refer patients with:

• eGFR <30 mL/min/1.73 m²
• Albuminuria ≥300 mg/24 hours
• Rapid decline in eGFR (>5 mL/min/1.73 m²/year)
• 5-year risk of end-stage renal disease >3-5% 1

Important Considerations and Pitfalls

• AKI Prevention: All CKD patients are at increased risk for acute kidney injury; avoid nephrotoxic medications when possible 2
• Medication Adjustments: Regularly review and adjust medications based on changing kidney function
• Therapeutic Inertia: Avoid delays in intensifying treatment when targets are not met 2
• Combination Therapy: A comprehensive approach addressing multiple risk factors simultaneously is more effective than focusing on single interventions 1

By implementing these evidence-based strategies, CKD progression can be slowed, complications reduced, and patient quality of life improved.