What are the treatment recommendations for chronic kidney disease?

Treatment Recommendations for Chronic Kidney Disease

The comprehensive management of chronic kidney disease (CKD) requires a multitargeted approach focusing on blood pressure control with renin-angiotensin system inhibitors, cardiovascular risk reduction with statins, and newer agents like SGLT2 inhibitors and nonsteroidal MRAs for specific populations to reduce morbidity, mortality, and preserve quality of life.

Risk Assessment and Monitoring

• Classify CKD risk using both eGFR and albuminuria levels according to KDIGO heat map 1
• Monitor eGFR and albuminuria at frequency based on risk category:
  • Low risk (G1A1, G2A1): Annual monitoring
  • Moderate risk (G1A2, G2A2, G3aA1): 1-2 times per year
  • High risk (G3aA3, G3bA2, G4-G5): 3-4 times per year 2, 1
• For diabetic patients: Assess urinary albumin and eGFR at least annually 2

Blood Pressure Management

• Target systolic BP <120 mmHg when tolerated using standardized office BP measurement 2
• For frail patients, those with fall risk, limited life expectancy, or postural hypotension, consider less intensive BP targets 2
• First-line agents:
  • ACE inhibitors or ARBs for patients with albuminuria (especially if >30 mg/g creatinine) 2, 1
  • Use highest approved dose that is tolerated 2
  • Monitor serum creatinine and potassium within 2-4 weeks of initiation or dose increase 2

Cardiovascular Risk Reduction

• Statin therapy recommendations:
  • Adults ≥50 years with eGFR <60 ml/min/1.73m²: Statin or statin/ezetimibe combination (strong recommendation) 2
  • Adults ≥50 years with eGFR ≥60 ml/min/1.73m²: Statin therapy (strong recommendation) 2
  • Adults 18-49 years: Consider statin if coronary disease, diabetes, prior stroke, or 10-year CV risk >10% 2
• Low-dose aspirin recommended for secondary prevention in patients with established cardiovascular disease 2
• For atrial fibrillation: Use NOACs in preference to warfarin for thromboprophylaxis in CKD G1-G4 2
  • Dose adjustment required based on GFR 2

Diabetes and CKD Management

• For patients with type 2 diabetes and CKD:
  • SGLT2 inhibitors are recommended 2
  • Consider adding nonsteroidal MRA (finerenone) to RASi and SGLT2i 2
  • Monitor potassium regularly when using MRAs, especially in patients with reduced GFR 2
  • For patients not achieving glycemic targets on metformin and SGLT2i, add long-acting GLP-1 receptor agonist 2

Dietary and Lifestyle Recommendations

• Protein intake: Maintain 0.8 g/kg body weight/day in adults with CKD G3-G5 2
  • Avoid high protein intake (>1.3 g/kg/day) in adults with CKD at risk of progression 2
  • For older adults with frailty/sarcopenia, consider higher protein targets 2
• Sodium: Restrict to <2 g sodium per day (<5 g sodium chloride) 2
• Consider plant-based "Mediterranean-style" diet to reduce cardiovascular risk 2, 1
• Physical activity: At least 150 minutes of moderate-intensity activity weekly 1
• Complete avoidance of tobacco products 1

Management of Metabolic Complications

• Acidosis: Consider pharmacological treatment if serum bicarbonate <18 mmol/l 2
• Hyperkalemia: Individualized approach including dietary and pharmacologic interventions 2
• Hyperuricemia: Treat with uric acid-lowering therapy if symptomatic 2
  • Xanthine oxidase inhibitors preferred over uricosuric agents 2
  • Do not use uric acid-lowering agents for asymptomatic hyperuricemia to delay CKD progression 2

Anemia Management

• For CKD patients with anemia:
  • Evaluate iron status before and during treatment 3
  • Administer supplemental iron when serum ferritin <100 mcg/L or transferrin saturation <20% 3
  • When using erythropoiesis-stimulating agents (ESAs):
    • Target hemoglobin <11 g/dL (avoid targeting >11 g/dL due to increased cardiovascular risks) 3
    • Use lowest dose sufficient to reduce need for RBC transfusions 3
    • Monitor hemoglobin weekly until stable, then monthly 3

Special Considerations

• For coronary artery disease: Initial conservative approach using intensive medical therapy is appropriate for stable ischemic heart disease 2
• For older adults: Evidence for ACE inhibitors/ARBs may have limited relevance to most persons >70 years 4
• For children with CKD: Target 24-hour mean arterial pressure by ABPM to ≤50th percentile for age, sex, and height 2

Referral to Nephrology

• Refer patients with:
  • eGFR <30 mL/min/1.73m²
  • Albuminuria ≥300 mg/24 hours
  • Rapid decline in eGFR (>5 mL/min/1.73m²/year)
  • Persistent proteinuria >1 g/day
  • Refractory hypertension requiring ≥4 antihypertensive agents 1

By implementing these evidence-based strategies, clinicians can effectively manage CKD to slow disease progression, reduce cardiovascular complications, and improve patient outcomes.