What is the initial treatment for patients with chronic kidney disease?

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, as first-line therapy for blood pressure control and renoprotection, particularly in patients with albuminuria. 1

Blood Pressure Management

Target Blood Pressure

• For patients with albuminuria ≥30 mg/24h: Target BP ≤130/80 mmHg 2
• For patients with albuminuria <30 mg/24h: Target BP ≤140/90 mmHg 2
• For children with CKD: Target mean arterial pressure ≤50th percentile for age, sex, and height 1

First-Line Antihypertensive Therapy

1. Patients with albuminuria (A2-A3 categories):

   • ACE inhibitor or ARB at maximum tolerated dose 1, 2
   • For patients with diabetes and albuminuria: ACE inhibitor or ARB is strongly recommended (1B) 1
   • For patients without diabetes but with severely increased albuminuria: ACE inhibitor or ARB is strongly recommended (1B) 1
   • For patients without diabetes but with moderately increased albuminuria: ACE inhibitor or ARB is suggested (2C) 1

2. Monitoring after RASi initiation:

   • 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

Additional Pharmacological Interventions

For Patients with Type 2 Diabetes and CKD

1. SGLT2 inhibitors:

   • Recommended for patients with eGFR ≥20 ml/min/1.73 m² (1A) 1
   • 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

2. GLP-1 receptor agonists:

   • Recommended for patients who haven't achieved glycemic targets despite metformin and SGLT2i (1B) 1
   • Prioritize agents with documented cardiovascular benefits 1

3. Nonsteroidal mineralocorticoid receptor antagonists (MRAs):

   • Consider for patients with T2D, eGFR >25 ml/min/1.73 m², normal potassium, and persistent albuminuria despite RASi (2A) 1
   • May be added to RASi and SGLT2i 1
   • Monitor potassium regularly after initiation 1

Cardiovascular Risk Reduction

1. Statin therapy:

   • For adults ≥50 years with eGFR <60 ml/min/1.73 m²: Statin or statin/ezetimibe combination (1A) 1
   • For adults ≥50 years with CKD and eGFR ≥60 ml/min/1.73 m²: Statin (1B) 1
   • For adults 18-49 years with CKD: Consider statin if they have coronary disease, diabetes, prior ischemic stroke, or 10-year cardiovascular risk >10% (2A) 1

2. Antiplatelet therapy:

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

Management of Metabolic Complications

1. Hyperkalemia management:

   • Individualized approach including dietary and pharmacologic interventions 1
   • Limit intake of foods rich in bioavailable potassium (e.g., processed foods) 1

2. Hyperuricemia management:

   • Treat symptomatic hyperuricemia with uric acid-lowering therapy (1C) 1
   • Xanthine oxidase inhibitors preferred over uricosuric agents 1
   • Not recommended to treat asymptomatic hyperuricemia to delay CKD progression (2D) 1

3. Metabolic acidosis:

   • Consider pharmacological treatment when serum bicarbonate <18 mmol/l 1
   • Monitor to avoid exceeding upper limit of normal 1

Lifestyle Modifications

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

Monitoring and Follow-up

• Regular monitoring of kidney function and albuminuria based on CKD stage 2
• Assess for risk of acute kidney injury with procedures and medications 2

Important Caveats

1. RASi initiation: Initial decline in GFR is common and expected, especially in proteinuric kidney disease. This is due to reduced intraglomerular pressure and does not necessarily indicate harm 1.

2. Hyperkalemia risk: Monitor potassium levels closely when using RASi, particularly in advanced CKD. Consider potassium binders rather than reducing RASi dose when possible 1.

3. Multiple medications: Achieving target BP often requires 3-4 antihypertensive agents, not just one 1. Poor BP control is common in CKD patients, with many receiving inadequate therapy.

4. Medication adjustments: Consider reducing or discontinuing RASi only if serum creatinine rises >30% or uncontrolled hyperkalemia develops despite treatment 1.