What are the treatment approaches for chronic kidney disease (CKD)?

Treatment Approaches for Chronic Kidney Disease (CKD)

The cornerstone of CKD management includes ACE inhibitors or ARBs for patients with albuminuria, SGLT2 inhibitors for those with diabetes, statins for cardiovascular risk reduction, and lifestyle modifications including a Mediterranean-style diet and blood pressure control. 1, 2

Classification and Diagnosis

• CKD is defined as kidney damage or glomerular filtration rate (GFR) <60 mL/min/1.73m² for three months or longer 1
• Classified based on:
  • GFR categories (G1-G5)
  • Albuminuria categories (A1-A3)

Pharmacological Interventions

Renin-Angiotensin System Blockade

• First-line therapy for patients with diabetes, hypertension, and albuminuria 2
• ACE inhibitors or ARBs should be titrated to the highest tolerated dose 2
• Reduction in urinary protein/albumin excretion is a critical treatment goal 1
• Monitor for hyperkalemia when using these medications

Glycemic Control in Diabetic CKD

• For type 2 diabetes with CKD:
  • SGLT2 inhibitors are recommended when eGFR ≥30 ml/min/1.73m² 2
  • Metformin as baseline therapy when appropriate 2
  • Tight glycemic control helps slow CKD progression 3

Cardiovascular Risk Reduction

• For adults ≥50 years with eGFR <60 ml/min/1.73m², use statin or statin/ezetimibe combination 1
• For adults ≥50 years with eGFR ≥60 ml/min/1.73m², use statin therapy 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
• Low-dose aspirin for secondary prevention in patients with established cardiovascular disease 1
• Consider PCSK-9 inhibitors for patients with indications for their use 1

Anemia Management

• Evaluate iron status before and during treatment 4
• Administer supplemental iron when serum ferritin is <100 mcg/L or transferrin saturation <20% 4
• For erythropoiesis-stimulating agents (ESAs):
  • Initiate when hemoglobin <10 g/dL
  • Target hemoglobin should not exceed 11 g/dL due to increased cardiovascular risks 4
  • Monitor hemoglobin weekly until stable, then monthly 4

Blood Pressure Management

• Target blood pressure:
  • <140/90 mmHg in patients without albuminuria
  • <130/80 mmHg in patients with albuminuria 2, 3
• Use ACE inhibitors or ARBs as first-line therapy, especially in patients with proteinuria 1, 2

Lifestyle Modifications

• Diet:
  • Plant-dominant, Mediterranean-style diet 1, 2
  • Low-sodium diet (<2g sodium/day) 2, 3
  • Low-protein diet may slow CKD progression 3
• Physical activity:
  • Regular walking and weight loss can slow CKD progression 3
• Avoid smoking and excessive alcohol consumption 3

Management of Complications

Metabolic Acidosis

• Consider sodium bicarbonate supplementation to maintain serum bicarbonate within normal range 5

Mineral and Bone Disorders

• Monitor and manage calcium, phosphorus, and parathyroid hormone levels 2
• Hyperphosphatemia management may slow progression 5

Hyperuricemia

• Avoid treating asymptomatic hyperuricemia solely to delay CKD progression 1
• For symptomatic hyperuricemia, xanthine oxidase inhibitors are preferred over uricosuric agents 2

Pain Management

• Acetaminophen (maximum 3g/day) as first-line pain management 2
• Avoid NSAIDs due to risk of renal toxicity 2
• For opioid requirements, fentanyl or buprenorphine are safest in advanced CKD 2

Monitoring and Follow-up

• Regular monitoring of:
  • Kidney function (eGFR and albuminuria)
  • Blood pressure
  • Glycemic control in diabetic patients
  • Electrolytes, particularly potassium with RAS blockade
  • Cardiovascular risk factors 2

Implementation of Care

• Multidisciplinary approach involving nephrologists, primary care physicians, and other specialists 1
• Early referral to nephrology care improves outcomes 1
• Disease management approaches and nurse-directed CKD care may be effective 1

Emerging Therapies

• Endothelin receptor antagonists like atrasentan show promise in diabetic CKD 3, 6
• Finerenone (non-steroidal mineralocorticoid receptor antagonist) 3
• Pentoxifylline may have anti-fibrotic and anti-inflammatory effects 3, 6

Common Pitfalls to Avoid

• Delayed referral to nephrology care
• Inadequate monitoring of medication side effects (hyperkalemia with ACE/ARBs)
• Overuse of NSAIDs and other nephrotoxic medications
• Targeting hemoglobin >11 g/dL with ESAs (increases cardiovascular risks)
• Inadequate attention to cardiovascular risk reduction
• Failure to adjust medication doses according to kidney function