What medications are recommended for patients with Chronic Kidney Disease (CKD)?

Medication Management for Chronic Kidney Disease (CKD)

For patients with chronic kidney disease, a comprehensive treatment approach should include ACE inhibitors or ARBs as first-line therapy, with SGLT2 inhibitors added for those with type 2 diabetes, and additional medications tailored to manage specific complications including hypertension, albuminuria, hyperkalemia, and cardiovascular risk. 1, 2

First-Line Medications

Renin-Angiotensin System (RAS) Blockade

• ACE inhibitors or ARBs are recommended first-line therapy for:
  • Patients with diabetes, hypertension, and albuminuria 1
  • Patients with albuminuria even with normal blood pressure 1, 2
  • Titrate to highest approved dose tolerated 1

Monitoring RAS Blockade

• Check serum creatinine and potassium within 2-4 weeks after starting or changing dose 1
• Continue therapy unless serum creatinine rises >30% within 4 weeks 1
• Do not discontinue for initial expected decrease in eGFR 2

Diabetes-Specific Medications

SGLT2 Inhibitors

• Add SGLT2 inhibitor for patients with type 2 diabetes and CKD with:
  • eGFR ≥20 ml/min per 1.73 m² 1, 2
  • Including those with urine ACR <200 mg/g (eGFR 20-45 ml/min per 1.73 m²) 1
• SGLT2 inhibitors reduce CKD progression and cardiovascular events 2
• Initial eGFR decrease with SGLT2 inhibitors is generally not a reason to discontinue 1

Other Diabetes Medications

• Metformin: First-line for T2D but reduce dose when eGFR <45 ml/min/1.73 m² and discontinue when <30 ml/min/1.73 m² 2
• GLP-1 receptor agonists: Recommended for patients not achieving glycemic targets despite metformin and SGLT2 inhibitors 1
  • Prioritize long-acting GLP-1 RAs with documented cardiovascular benefits 1

Additional Medications Based on CKD Complications

Mineralocorticoid Receptor Antagonists (MRAs)

• Nonsteroidal MRAs (e.g., finerenone) suggested for:
  • T2D patients with eGFR >25 ml/min per 1.73 m²
  • Normal serum potassium
  • Persistent albuminuria despite maximum RAS inhibitor dose 1
• Can be added to RASi and SGLT2i regimen 1
• Monitor potassium regularly after initiation 1

Lipid Management

• Statins recommended for:
  • All adults ≥50 years with eGFR <60 ml/min per 1.73 m² 1, 2
  • All adults ≥50 years with CKD and eGFR ≥60 ml/min per 1.73 m² 1
  • Adults 18-49 years with CKD and coronary disease, diabetes, prior stroke, or >10% 10-year cardiovascular risk 1

Antiplatelet Therapy

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

Anemia Management

• Epoetin alfa for anemia in CKD:
  • Initial dose: 50-100 Units/kg three times weekly for adults 3
  • Individualize maintenance dose 3
  • Evaluate iron status before and during treatment 3

Metabolic Acidosis Management

• Consider pharmacological treatment for serum bicarbonate <18 mmol/l 1
• Monitor to ensure treatment doesn't cause bicarbonate to exceed upper limit of normal 1

Hyperkalemia Management

• Implement individualized approach including dietary and pharmacologic interventions 1
• Limit intake of foods rich in bioavailable potassium (e.g., processed foods) 1
• Consider potassium binders if hyperkalemia limits optimal RAS inhibitor dosing 2

Hyperuricemia Treatment

• Treat symptomatic hyperuricemia with uric acid-lowering therapy 1
• Consider xanthine oxidase inhibitors rather than uricosuric agents 1
• Avoid uric acid-lowering agents for asymptomatic hyperuricemia 1

Cardiovascular Protection

• Anticoagulation for atrial fibrillation: Non-vitamin K antagonist oral anticoagulants (NOACs) preferred over warfarin for CKD G1-G4 1
• Blood pressure control: Target <130/80 mmHg for most CKD patients 4
• Combination therapy: Often needed to achieve BP targets in CKD 4, 5
• Sodium restriction: <2g per day for most CKD patients 2

Important Cautions

• Avoid dual RAS blockade (ACEi + ARB or direct renin inhibitors) due to increased adverse effects 2
• Pregnancy: Discontinue ACEi/ARB in women considering pregnancy or who become pregnant 1
• Hyperkalemia risk: Higher with RAS blockade, especially in advanced CKD 6
• Medication adjustments: Many medications require dose adjustment or avoidance in advanced CKD 7

By following this evidence-based approach to medication management in CKD, clinicians can effectively slow disease progression, reduce cardiovascular complications, and improve patient outcomes.