What are the guidelines for family practice management of Chronic Kidney Disease (CKD)?

Family Practice Management of Chronic Kidney Disease

Family physicians should implement a comprehensive CKD management strategy focusing on lifestyle modifications, blood pressure control, and appropriate referral to nephrology based on risk stratification to reduce morbidity and mortality in patients with CKD. 1

Diagnosis and Risk Assessment

• Classify CKD using the KDIGO heat map based on eGFR and albuminuria categories:
  • eGFR categories: G1 (≥90), G2 (60-89), G3a (45-59), G3b (30-44), G4 (15-29), G5 (<15 ml/min/1.73m²)
  • Albuminuria categories: A1 (<30 mg/g), A2 (30-300 mg/g), A3 (>300 mg/g) 2
• Risk levels:
  • Low risk (green): G1A1, G2A1
  • Moderate risk (yellow): G1A2, G2A2, G3aA1
  • High risk (orange): G1A3, G2A3, G3aA2, G3bA1
  • Very high risk (red): G3aA3, G3bA2-3, G4A1-3, G5A1-3 2

Lifestyle Modifications

Physical Activity

• Recommend moderate-intensity physical activity for at least 150 minutes per week, adjusted to cardiovascular and physical tolerance 1, 2
• Advise patients to avoid sedentary behavior 1
• For patients at higher fall risk, provide specific advice on exercise intensity (low, moderate, or vigorous) and type (aerobic vs. resistance) 1
• For children with CKD, encourage ≥60 minutes of daily physical activity 1

Diet

• Advise healthy, diverse diets with more plant-based foods and fewer animal-based and ultra-processed foods 1, 2
• Restrict sodium intake to <2 g/day (or <5 g sodium chloride/day), except in sodium-wasting nephropathy 1, 2
• Protein recommendations:
  • Maintain protein intake at 0.8 g/kg/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
  • For very high-risk patients, consider supervised very low-protein diet (0.3-0.4 g/kg/day) with amino acid or ketoacid supplements 1
  • For older adults with frailty/sarcopenia, consider higher protein and calorie targets 1
  • Do not restrict protein in children with CKD 1
• Refer to renal dietitians for individualized dietary education 1, 2

Weight Management

• Advise weight loss for patients with obesity and CKD 1
• Aim for optimal BMI 1

Tobacco Use

• Strongly recommend complete avoidance of tobacco products 1, 2
• Refer to smoking cessation programs when needed 1, 2

Blood Pressure Management

• Target systolic BP <120 mmHg using standardized office measurement when tolerated 1
• Use less intensive BP targets for patients with frailty, fall risk, limited life expectancy, or postural hypotension 1
• For children with CKD, target 24-hour mean arterial pressure by ABPM to ≤50th percentile for age, sex, and height 1
• First-line therapy: ACE inhibitor or ARB at maximally tolerated dose, particularly for patients with albuminuria 2
• Add-on therapy: dihydropyridine calcium channel blocker and/or diuretic 2
• Consider finerenone (non-steroidal mineralocorticoid receptor antagonist) if albuminuria persists despite first-line therapy 2
• Check potassium and creatinine 1-2 weeks after starting or increasing ACE inhibitor/ARB dose 2

Monitoring and Follow-up

• Monitor eGFR and albuminuria based on risk category:
  • Low risk: Annual
  • Moderate risk: 1-2 times per year
  • High/very high risk: 3-4 times per year 2
• Monitor blood pressure every 3-6 months 2
• For diabetic patients, monitor HbA1c every 3-6 months with target <7% 2

Medication Management

• Review all medications, including over-the-counter and herbal remedies, for potential nephrotoxicity 2
• Adjust medication dosing based on GFR for renally cleared drugs 2
• Monitor therapeutic levels for drugs with narrow therapeutic windows 2
• Consider statin therapy for patients with CKD aged >50 years 2
• Consider low-dose aspirin for patients with established cardiovascular disease or high ASCVD risk 2

Nephrology Referral Criteria

Refer to nephrology when:

• eGFR <30 mL/min/1.73m² 2
• Albuminuria ≥300 mg/g or mg/24 hours 2
• Rapid decline in eGFR (>5 mL/min/1.73m²/year) 2
• Difficulty managing hypertension 2
• Persistent electrolyte abnormalities 2
• 5-year risk of end-stage renal disease >3-5% 2

Common Pitfalls and Caveats

• Don't rely solely on serum creatinine to detect CKD; calculate eGFR using prediction equations 3
• Don't overlook albuminuria in patients with normal eGFR; it's an important marker of kidney damage and cardiovascular risk 3
• Don't prescribe low-protein diets for metabolically unstable patients with CKD 1
• Don't restrict protein in children with CKD due to growth impairment risk 1
• Don't delay lifestyle interventions while waiting for pharmacological treatments to work; healthy eating and physical activity are essential for slowing CKD progression 4
• Don't focus solely on current kidney function; progression rate is the primary driver of adverse outcomes 4
• Don't overlook cardiovascular risk management; CKD patients have elevated cardiovascular risk even with mild kidney dysfunction 5