What is the initial management for patients with Chronic Kidney Disease (CKD)?

Initial Management of Chronic Kidney Disease (CKD)

The initial management of CKD should focus on blood pressure control, use of renin-angiotensin system inhibitors, cardiovascular risk reduction, and regular monitoring of kidney function and albuminuria based on the patient's CKD stage and risk factors.

Blood Pressure Management

• Target blood pressure:

  • For patients with albuminuria <30 mg/24h: ≤140/90 mmHg 1
  • For patients with albuminuria ≥30 mg/24h: ≤130/80 mmHg 1
  • For children with CKD: Target mean arterial pressure ≤50th percentile for age, sex, and height 1

• First-line antihypertensive therapy:

  • For patients with albuminuria ≥30 mg/24h: ACE inhibitor or ARB 1
  • For Black patients: Start with thiazide diuretic or calcium channel blocker 1
  • For non-Black patients: ACE inhibitor, ARB, thiazide diuretic, or calcium channel blocker 1

Renin-Angiotensin System Inhibitors (RASi)

• Indications for RASi (ACEi or ARB):

  • Strongly recommended for patients with severely increased albuminuria (>300 mg/24h) with or without diabetes 1
  • Recommended for patients with moderately increased albuminuria (30-300 mg/24h) with diabetes 1
  • Suggested for patients with moderately increased albuminuria without diabetes 1
  • Consider for patients with normal to mildly increased albuminuria who have hypertension or heart failure 1

• RASi dosing and monitoring:

  • Use highest approved dose that is tolerated 1
  • Check serum creatinine and potassium within 2-4 weeks of initiation or dose increase 1
  • Continue therapy unless serum creatinine rises by >30% within 4 weeks of starting treatment 1
  • Continue even when eGFR falls below 30 ml/min/1.73 m² 1

SGLT2 Inhibitors

• Recommended for:

  • Patients with type 2 diabetes, CKD, and eGFR ≥20 ml/min/1.73 m² 1
  • Adults with CKD, eGFR ≥20 ml/min/1.73 m² with urine ACR ≥200 mg/g 1
  • Patients with heart failure, irrespective of albuminuria level 1

• Practical considerations:

  • Can continue even if eGFR falls below 20 ml/min/1.73 m² unless not tolerated 1
  • Consider withholding during prolonged fasting, surgery, or critical illness 1

Cardiovascular Risk Reduction

• Statin therapy:

  • Recommended for adults ≥50 years with eGFR <60 ml/min/1.73 m² 1
  • Recommended for adults ≥50 years with CKD and eGFR ≥60 ml/min/1.73 m² 1
  • Consider for adults 18-49 years with CKD who have coronary disease, diabetes, prior stroke, or elevated cardiovascular risk 1

• Antiplatelet therapy:

  • Low-dose aspirin recommended for secondary prevention in patients with established cardiovascular disease 1
  • Consider P2Y12 inhibitors when aspirin is not tolerated 1

Monitoring and Follow-up

• Frequency of monitoring based on CKD stage and albuminuria:
  • Higher risk patients (lower GFR, higher albuminuria): More frequent monitoring
  • Annual monitoring of kidney function and albuminuria for stable patients 2
  • Monitor for complications: hyperkalemia, metabolic acidosis, hyperphosphatemia, vitamin D deficiency, anemia 3

Lifestyle Modifications

• Sodium restriction (<2g/day) 1
• Maintain healthy body weight (BMI 20-25 kg/m²) 1
• Regular exercise (30 minutes, 5 times weekly) 1
• Smoking cessation 1
• Consider Mediterranean-style diet 1

Avoiding Nephrotoxins

• Avoid NSAIDs when possible 3
• Adjust medication dosages based on kidney function 2
• Consider risk of acute kidney injury with procedures and medications 1

Common Pitfalls to Avoid

1. Discontinuing RASi prematurely: Continue ACEi/ARB unless serum creatinine rises >30% or uncontrolled hyperkalemia develops 1

2. Inadequate monitoring: Failure to monitor kidney function, albuminuria, and electrolytes at appropriate intervals based on CKD stage

3. Overlooking cardiovascular risk: CKD patients have high cardiovascular risk requiring aggressive management with statins and blood pressure control

4. Inappropriate blood pressure targets: Using the same target for all patients rather than individualizing based on albuminuria status

5. Medication errors: Failing to adjust medication dosages based on declining kidney function

By following this comprehensive approach to CKD management, focusing on blood pressure control, RASi therapy, cardiovascular risk reduction, and appropriate monitoring, progression to end-stage kidney disease can be delayed and patient outcomes improved.