What is the recommended management plan for patients with kidney disease?

Comprehensive Management Plan for Patients with Chronic Kidney Disease

Patients with chronic kidney disease (CKD) should be treated with a comprehensive strategy that includes lifestyle modifications, first-line drug therapies based on clinical characteristics, and additional medications with proven kidney and heart protection to reduce risks of kidney disease progression and cardiovascular disease. 1

Risk Assessment and Classification

• Classify CKD using both GFR categories (G1-G5) and albuminuria categories (A1-A3)
• Adjust monitoring frequency based on CKD severity:
  • G1-G2/A1: Annual monitoring
  • G3a/A1 or G1-G2/A2: 1-2 times per year
  • G4-G5/Any or Any/A3: 3-4 times per year 2
• Regular risk factor reassessment every 3-6 months 1

First-Line Interventions

Lifestyle Modifications (All Patients)

• Diet:

  • Plant-based "Mediterranean-style" diet 1
  • Sodium restriction <2000 mg/day 2
  • Limit intake of foods rich in bioavailable potassium for patients with CKD G3-G5 with history of hyperkalemia 1
  • Limit alcohol, meats, and high-fructose corn syrup to prevent gout 1

• Physical Activity:

  • 150 minutes/week of moderate-intensity exercise, adjusted to cardiovascular tolerance 2, 3

• Other Lifestyle Factors:

  • Complete smoking cessation 1, 2
  • Weight management and reduction if obese 2, 3

Pharmacological Management

Blood Pressure Control

• Target: <120 mmHg systolic using standardized measurement 2
• First-line therapy:
  • ACE inhibitor or ARB for patients with albuminuria and hypertension, titrated to highest tolerated dose 1
  • Add dihydropyridine calcium channel blocker and/or diuretic if needed to achieve BP target 1, 4

Glycemic Control

• Type 1 Diabetes: Insulin-based therapy 1
• Type 2 Diabetes:
  • Metformin (if eGFR ≥30 ml/min/1.73 m²) 1
  • SGLT2 inhibitors (initiate if eGFR ≥20 ml/min/1.73 m²; continue until dialysis or transplant) 1, 5
  • GLP-1 receptor agonists if additional glycemic control needed or unable to use SGLT2i/metformin 1, 5

Lipid Management

• Statin therapy:
  • Adults ≥50 years with eGFR <60 ml/min/1.73 m²: Statin or statin/ezetimibe combination 1
  • Adults ≥50 years with eGFR ≥60 ml/min/1.73 m²: Statin 1
  • Adults 18-49 years with CKD: Statin if they have coronary disease, diabetes, prior ischemic stroke, or 10-year cardiovascular risk >10% 1
  • Consider PCSK9 inhibitors for patients with indications 1

Additional Risk-Based Therapies

• Nonsteroidal mineralocorticoid receptor antagonist (finerenone) for patients with T2D and albuminuria ≥30 mg/g with normal potassium 1, 5
• Steroidal mineralocorticoid receptor antagonist for resistant hypertension 1
• Antiplatelet therapy:
  • Low-dose aspirin for secondary prevention in patients with established cardiovascular disease 1
  • Consider other antiplatelet therapy (e.g., P2Y12 inhibitors) when aspirin intolerant 1
• Additional lipid-lowering therapy (ezetimibe, PCSK9 inhibitors, icosapent ethyl) based on ASCVD risk and lipid levels 1

Management of CKD Complications

Hyperuricemia

• Treat symptomatic hyperuricemia with uric acid-lowering therapy 1
• Prefer xanthine oxidase inhibitors over uricosuric agents 1
• For acute gout, use low-dose colchicine or intra-articular/oral glucocorticoids rather than NSAIDs 1
• Do not use uric acid-lowering agents for asymptomatic hyperuricemia to delay CKD progression 1

Metabolic Acidosis

• Treat when bicarbonate <18 mmol/L 2

Anemia

• Evaluate and treat according to KDIGO guidelines 2

Monitoring and Follow-up

• Regular assessment of:
  • Kidney function (eGFR)
  • Albuminuria
  • Blood pressure
  • Glycemic control (in diabetes)
  • Lipid levels
  • Cardiovascular risk factors 1, 2

Referral to Nephrology

• 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% 2

Common Pitfalls and Caveats

1. Avoid combining ACE inhibitors, ARBs, and direct renin inhibitors due to increased risk of hyperkalemia and acute kidney injury 2

2. Monitor for hyperkalemia when using RAS blockers or mineralocorticoid receptor antagonists, especially in advanced CKD 1

3. Adjust medication dosages as kidney function deteriorates to avoid adverse effects 1

4. Avoid NSAIDs in patients with CKD due to risk of further kidney injury 6

5. Do not delay initiation of evidence-based therapies - therapeutic inertia is common despite high residual risks of CKD progression and cardiovascular disease 1