What medications are used to manage Chronic Kidney Disease (CKD)?

Medications for Managing Chronic Kidney Disease

For patients with chronic kidney disease (CKD), the cornerstone medications include renin-angiotensin system inhibitors (ACEi/ARBs), SGLT2 inhibitors, and other targeted therapies based on specific complications, with medication selection guided by albuminuria status, eGFR, and comorbidities.

First-Line Medications for CKD

Renin-Angiotensin System Inhibitors

• ACE inhibitors or ARBs are recommended first-line therapy for:

  • Patients with CKD and severely increased albuminuria (G1-G4, A3) without diabetes (strong recommendation) 1
  • Patients with CKD and moderately increased albuminuria (G1-G4, A2) without diabetes (suggested) 1
  • Patients with CKD and moderately-to-severely increased albuminuria (G1-G4, A2 and A3) with diabetes (strong recommendation) 1
  • Patients with hypertension and albuminuria 1

• Dosing considerations:

  • Use highest approved dose that is tolerated 1
  • Monitor serum creatinine and potassium within 2-4 weeks of initiation or dose increase 1
  • Continue even when eGFR falls below 30 ml/min/1.73 m² 1
  • Consider discontinuing only if serum creatinine rises >30% within 4 weeks, uncontrolled hyperkalemia occurs, or symptomatic hypotension develops 1

SGLT2 Inhibitors

• Strongly recommended for patients with type 2 diabetes, CKD, and eGFR ≥20 ml/min/1.73 m² 1
• Benefits include:
  • Slowing CKD progression
  • Reducing heart failure risk
  • Cardiovascular protection
  • Note: Glucose-lowering efficacy decreases when eGFR falls below 45 ml/min/1.73 m² 1

GLP-1 Receptor Agonists

• Semaglutide can be used as a first-line agent for people with CKD 1
• Benefits include:
  • Effective glucose control regardless of kidney function
  • Low hypoglycemia risk
  • Cardiovascular risk reduction
  • Potential kidney benefits 1

Medications for CKD Complications

Blood Pressure Management

• Target blood pressure:
  • <120 mmHg systolic when tolerated for adults with CKD 1
  • For children with CKD: 24-hour mean arterial pressure ≤50th percentile for age, sex, and height 1
• Medication strategy:
  1. Start with ACEi/ARB if albuminuria present
  2. Add dihydropyridine calcium channel blockers or diuretics if needed
  3. Consider less intensive BP targets in frail patients or those with fall risk 1, 2

Lipid Management

• Statins or statin/ezetimibe combination:
  • Adults ≥50 years with eGFR <60 ml/min/1.73 m² (G3a-G5) 1
  • Adults ≥50 years with CKD and eGFR ≥60 ml/min/1.73 m² (G1-G2) 1
  • Adults 18-49 years with CKD and coronary disease, diabetes, prior stroke, or 10-year cardiovascular risk >10% 1
• Consider PCSK9 inhibitors for patients with indications for their use 1

Mineral and Bone Disorder Management

• Phosphate binders (e.g., sevelamer) for hyperphosphatemia 3
• Vitamin D analogs for secondary hyperparathyroidism
• Calcimimetics for resistant secondary hyperparathyroidism

Anemia Management

• Erythropoiesis-stimulating agents (e.g., epoetin alfa) for anemia of CKD 4
  • Use lowest dose sufficient to reduce need for transfusions
  • Target hemoglobin <11 g/dL to avoid cardiovascular risks
  • Evaluate iron status before and during treatment

Acidosis Management

• Oral sodium bicarbonate for metabolic acidosis
• Target serum bicarbonate levels in normal range

Dietary and Lifestyle Recommendations

• Sodium restriction: <2g sodium per day (<5g sodium chloride) 1, 2
• Protein intake: 0.6-0.8 g/kg/day for adults with CKD G3 2
• Plant-based "Mediterranean-style" diet to reduce cardiovascular risk 1, 2
• Physical activity: At least 150 minutes of moderate-intensity activity weekly 2
• Smoking cessation for all patients with CKD 1, 2

Monitoring and Dose Adjustments

• ACEi/ARB monitoring:

  • Check serum creatinine and potassium 2-4 weeks after initiation/dose change 1
  • Continue unless creatinine rises >30% or uncontrolled hyperkalemia develops 1

• Metformin adjustments:

  • Contraindicated if eGFR <30 ml/min/1.73 m² 1
  • Reassess benefits/risks when eGFR <45 ml/min/1.73 m² 1
  • Do not initiate if eGFR <45 ml/min/1.73 m² 1

• Regular monitoring:

  • eGFR and albuminuria based on risk category (1-4 times per year) 2
  • Blood pressure every 3-6 months 2
  • Lipid profile annually
  • Hemoglobin, calcium, phosphorus, PTH, and vitamin D as appropriate for CKD stage

Important Cautions

• Avoid combination of ACEi, ARB, and direct renin inhibitors - increases adverse effects without additional benefits 1
• Avoid NSAIDs - can worsen kidney function
• Adjust medication doses for reduced kidney function (especially antibiotics and hypoglycemic agents) 5
• Monitor for hyperkalemia with ACEi/ARB use - can often be managed without discontinuing therapy 1
• Be cautious with contrast media - may require prophylaxis or temporary medication adjustments

By following this comprehensive medication approach based on the latest guidelines, CKD progression can be slowed, complications managed, and patient outcomes improved.