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

Initial Management of Chronic Kidney Disease

The initial management of chronic kidney disease (CKD) should focus on blood pressure control, use of renin-angiotensin system inhibitors, cardiovascular risk reduction, and regular monitoring of kidney function and albuminuria based on the patient's CKD stage and risk factors. 1

Blood Pressure Management

Blood Pressure Targets

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

First-line Antihypertensive Therapy

• For patients with albuminuria ≥30 mg/24h: ACE inhibitor or ARB 2, 1
• For Black patients: Thiazide diuretic or calcium channel blocker 1
• For non-Black patients: ACE inhibitor, ARB, thiazide diuretic, or calcium channel blocker 1

Renin-Angiotensin System Inhibitors (RASi)

Indications for RASi

• Severely increased albuminuria (>300 mg/24h) without diabetes: Strongly recommended (ACEi or ARB) 2
• Moderately increased albuminuria (30-300 mg/24h) without diabetes: Suggested (ACEi or ARB) 2
• Moderately-to-severely increased albuminuria with diabetes: Strongly recommended (ACEi or ARB) 2

RASi Dosing and Monitoring

• Use highest approved dose that is tolerated 2
• Check serum creatinine and potassium within 2-4 weeks of initiation or dose increase 2
• Continue therapy unless serum creatinine rises by >30% within 4 weeks of starting treatment 2
• Continue RASi even when eGFR falls below 30 ml/min/1.73 m² 2
• Avoid combination of ACEi, ARB, and direct renin inhibitor therapy 2

Cardiovascular Risk Reduction

Statin Therapy

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

Antiplatelet Therapy

• Low-dose aspirin for secondary prevention in patients with established cardiovascular disease 2
• Consider P2Y12 inhibitors when aspirin is not tolerated 2

Additional Pharmacological Therapies

For Diabetic CKD

• SGLT2 inhibitors: Recommended for patients with T2D, CKD, and eGFR ≥20 ml/min/1.73 m² 2
• Continue SGLT2i even if eGFR falls below 20 ml/min/1.73 m² unless not tolerated or kidney replacement therapy is initiated 2
• Withhold SGLT2i during prolonged fasting, surgery, or critical illness 2

For Non-diabetic CKD with Albuminuria

• SGLT2 inhibitors: Recommended for adults with eGFR ≥20 ml/min/1.73 m² with urine ACR ≥200 mg/g or heart failure 2
• Nonsteroidal MRA (finerenone): Consider for adults with T2D, eGFR >25 ml/min/1.73 m², normal potassium, and albuminuria despite maximum RASi 2

Lifestyle Modifications

• Sodium restriction (<2g/day) 1
• Maintain healthy body weight (BMI 20-25 kg/m²) 1
• Regular exercise (30 minutes, 5 times weekly) 1
• Smoking cessation 1
• Consider Mediterranean-style diet 2
• Dietary protein intake should be maximum 0.8 g/kg body weight per day for non-dialysis CKD stage 3 or higher 2

Monitoring and Follow-up

• Annual monitoring of kidney function and albuminuria for stable patients 1
• Evaluate iron status in all patients and administer supplemental iron when serum ferritin <100 mcg/L or transferrin saturation <20% 3
• For patients requiring erythropoiesis-stimulating agents, monitor hemoglobin weekly until stable, then monthly 3

Common Pitfalls and Caveats

1. RASi initiation: Don't discontinue for minor increases in serum creatinine (≤30%) in the absence of volume depletion 2
2. SGLT2i monitoring: The reversible decrease in eGFR on initiation is generally not an indication to discontinue therapy 2
3. Hyperkalemia management: Hyperkalemia associated with RASi can often be managed by measures to reduce potassium levels rather than decreasing the dose or stopping RASi 2
4. Anemia evaluation: Before initiating erythropoiesis-stimulating agents, correct or exclude other causes of anemia (vitamin deficiency, inflammation, bleeding) 3
5. BP measurement: Use 24-hour ambulatory devices when possible for more accurate assessment 2

By implementing this comprehensive approach to CKD management, focusing on blood pressure control, appropriate use of RASi, cardiovascular risk reduction, and lifestyle modifications, progression of kidney disease can be slowed and cardiovascular outcomes improved.