Initial Treatment for Chronic Kidney Disease
The initial treatment for patients with chronic kidney disease should focus on renin-angiotensin system inhibitors (RASi), specifically ACE inhibitors or ARBs, for patients with albuminuria, along with blood pressure control, SGLT2 inhibitors for appropriate patients, and statin therapy for cardiovascular risk reduction. 1, 2
Blood Pressure Control and RASi Therapy
RASi Recommendations Based on Albuminuria:
- For patients with severely increased albuminuria (>300 mg/g or A3): Start ACE inhibitor or ARB regardless of diabetes status (strong recommendation) 1
- For patients with moderately increased albuminuria (30-300 mg/g or A2) with diabetes: Start ACE inhibitor or ARB (strong recommendation) 1
- For patients with moderately increased albuminuria without diabetes: Consider ACE inhibitor or ARB (suggested) 1
Blood Pressure Targets:
- For patients with albuminuria: Target BP ≤130/80 mmHg 2
- For patients without albuminuria: Target BP ≤140/90 mmHg 2
RASi Dosing and Monitoring:
- Use the highest approved dose that is tolerated 1
- Check serum creatinine and potassium within 2-4 weeks of initiation or dose increase 1
- Continue RASi unless serum creatinine rises by >30% within 4 weeks 1
- Continue RASi even when eGFR falls below 30 ml/min/1.73 m² 1
SGLT2 Inhibitors
- For patients with type 2 diabetes and eGFR ≥20 ml/min/1.73 m²: Start SGLT2 inhibitor (strong recommendation) 1
- For patients with eGFR ≥20 ml/min/1.73 m² with urine ACR ≥200 mg/g or heart failure: Start SGLT2 inhibitor regardless of diabetes status (strong recommendation) 1
- For patients with eGFR 20-45 ml/min/1.73 m² with urine ACR <200 mg/g: Consider SGLT2 inhibitor (suggested) 1
Cardiovascular Risk Reduction
Statin Therapy:
- For adults ≥50 years with eGFR <60 ml/min/1.73 m²: Start statin or statin/ezetimibe combination (strong recommendation) 1
- For adults ≥50 years with CKD and eGFR ≥60 ml/min/1.73 m²: Start statin (strong recommendation) 1
- For adults 18-49 years with CKD: Start statin if they have coronary disease, diabetes, prior ischemic stroke, or 10-year cardiovascular risk >10% (suggested) 1
Antiplatelet Therapy:
- For patients with established cardiovascular disease: Use low-dose aspirin for secondary prevention 1
- Consider P2Y12 inhibitors when aspirin is not tolerated 1
Additional Treatments
Nonsteroidal Mineralocorticoid Receptor Antagonists:
- Consider for patients with type 2 diabetes, eGFR >25 ml/min/1.73 m², normal potassium, and persistent albuminuria despite RASi 1
- Monitor potassium regularly after initiation 1
GLP-1 Receptor Agonists:
- For patients with type 2 diabetes and CKD who haven't achieved glycemic targets despite metformin and SGLT2 inhibitor treatment 1
- Prioritize agents with documented cardiovascular benefits 1
Hyperuricemia Management:
- Treat symptomatic hyperuricemia (gout) with uric acid-lowering therapy 1
- Prefer xanthine oxidase inhibitors over uricosuric agents 1
- Do not treat asymptomatic hyperuricemia to delay CKD progression 1
Lifestyle Modifications
- Recommend sodium restriction (<2g/day) 2
- Advise maintaining healthy body weight (BMI 20-25 kg/m²) 2
- Encourage regular exercise (30 minutes, 5 times weekly) 2
- Strongly recommend smoking cessation 2
- Consider a plant-based "Mediterranean-style" diet 1
Common Pitfalls and Caveats
RASi Discontinuation: Many clinicians inappropriately discontinue RASi when serum creatinine rises slightly. Continue unless rise exceeds 30% or uncontrollable hyperkalemia develops 1
Insufficient Dosing: Most patients require multiple antihypertensive medications to reach target BP. Using only one agent is usually inadequate 1
Hyperkalemia Management: Hyperkalemia with RASi can often be managed with dietary modifications and medications rather than discontinuing the RASi 1
SGLT2i Precautions: Consider withholding SGLT2 inhibitors during prolonged fasting, surgery, or critical illness due to ketosis risk 1
Monitoring Requirements: Regular monitoring of kidney function, albuminuria, and electrolytes is essential, with frequency based on CKD stage and treatment regimen 2