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

Initial Management Approach for Chronic Kidney Disease (CKD)

The initial management of CKD should focus on blood pressure control with a target of <140/90 mmHg using renin-angiotensin system inhibitors (ACEIs or ARBs) as first-line therapy, particularly in patients with albuminuria. 1

Blood Pressure Management

Target Blood Pressure

• For most CKD patients not on dialysis: <140/90 mmHg 1
• For CKD patients with albuminuria >300 mg/24h: <130/80 mmHg 1
• For elderly patients (>60 years): <150/90 mmHg 1

First-Line Antihypertensive Medications

• For CKD patients with albuminuria (>30 mg/24h): ACE inhibitor or ARB 1
  • Strong recommendation (1B) for those with severely increased albuminuria (>300 mg/24h)
  • Suggested (2C) for those with moderately increased albuminuria (30-300 mg/24h)
• For CKD patients without albuminuria: Thiazide diuretic, calcium channel blocker, ACEI, or ARB 1
• For Black patients with CKD: Initial therapy with thiazide diuretic or calcium channel blocker 1
  • Add ACEI/ARB if proteinuria is present

Lifestyle Modifications

• Salt restriction (crucial for hypertension management in CKD) 1, 2
• Weight reduction for overweight/obese patients
• Regular physical activity
• Smoking cessation
• Alcohol moderation

Lipid Management

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

Antiplatelet Therapy

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

Monitoring Recommendations

• Check serum creatinine and potassium within 2-4 weeks after starting or increasing ACEI/ARB dose 3
• Monitor for postural hypotension regularly when treating with BP-lowering drugs 1
• Continue ACEI/ARBs despite mild-moderate increases in creatinine (up to 30%) 3
• Be aware that SGLT2 inhibitors may cause an initial reversible decrease in eGFR 3

Important Considerations

1. Expect initial eGFR decline: A small decrease in eGFR (up to 30%) after starting ACEI/ARB is expected and not a reason to discontinue therapy unless hyperkalemia develops 3

2. Medication combinations: Many patients will require multiple medications to achieve target BP 1

3. Hyperkalemia management: Implement dietary modifications or consider potassium binders before reducing doses of beneficial medications like ACEI/ARBs 3

4. Individualization: While following these guidelines, consider patient age, comorbidities, risk of CKD progression, and medication tolerance 1

5. Avoid common pitfalls:

   • Don't discontinue ACEI/ARB due to expected initial eGFR decline
   • Don't use non-dihydropyridine CCBs as monotherapy in proteinuric CKD patients 4
   • Don't overlook the importance of diuretics in fluid management 4

By following this approach to initial CKD management with appropriate blood pressure control, lipid management, and lifestyle modifications, you can significantly reduce the risk of CKD progression and cardiovascular events in these patients.