What are the management strategies for Chronic Kidney Disease (CKD)?

Management Strategies for Chronic Kidney Disease (CKD)

The comprehensive management of chronic kidney disease requires a holistic approach focusing on lifestyle modifications, dietary interventions, pharmacological therapies, and regular monitoring to reduce progression and manage complications, with SGLT2 inhibitors, RAS inhibitors, and statin therapy forming the cornerstone of pharmacological management. 1

Risk Assessment and Stratification

• Use validated risk prediction models that incorporate eGFR and albuminuria to guide preventive therapies 1
• Classify patients using the KDIGO heat map based on eGFR and albuminuria levels to determine risk of progression and cardiovascular events 1, 2
• Monitor eGFR and albuminuria regularly based on risk category:
  • Low risk (G1-G2, A1): Annual monitoring
  • Moderate risk (G3a, A1 or G1-G2, A2): 1-2 times per year
  • High risk (G4-G5, any albuminuria or any GFR with A3): 3-4 times per year 2

Lifestyle Modifications

• Physical Activity: Recommend at least 150 minutes of moderate-intensity physical activity per week, adjusted to cardiovascular and physical tolerance 1
• Weight Management: Encourage optimal BMI (20-25 kg/m²) through weight loss for patients with obesity 1, 2
• Tobacco Cessation: Complete avoidance of tobacco products with referral to smoking cessation programs 1
• Sedentary Behavior: Advise against prolonged sedentary behavior 1
• Fall Prevention: For patients at higher risk of falls, provide specific advice on exercise intensity (low, moderate, or vigorous) and type (aerobic vs. resistance) 1

Dietary Management

• Diet Type: Recommend plant-dominant, Mediterranean-style diets with higher consumption of plant-based foods compared to animal-based foods 1, 2
• Protein Intake: Maintain protein intake at 0.8 g/kg/day for adults with CKD G3-G5 1, 2
  • Avoid high protein intake (>1.3 g/kg/day) in adults with CKD at risk of progression 1
  • Consider very low-protein diet (0.3-0.4 g/kg/day) with essential amino acid or ketoacid supplements for high-risk patients under close supervision 1, 3
  • Do not restrict protein in metabolically unstable patients 1
• Sodium Intake: Restrict to <2 g/day to reduce blood pressure and proteinuria 1, 2
• Processed Foods: Reduce consumption of ultraprocessed foods 1
• Dietitian Involvement: Utilize renal dietitians or accredited nutrition providers to educate patients about dietary adaptations 1

Pharmacological Management

Blood Pressure Control

• Target BP: <130/80 mmHg for patients with albuminuria; <140/90 mmHg for those without albuminuria 2, 4
• First-line Therapy:
  • ACE inhibitors or ARBs for patients with albuminuria 1, 2
  • Dihydropyridine calcium channel blockers or diuretics can be first-line if no albuminuria 1, 2
• Add-on Therapy:
  • Dihydropyridine calcium channel blockers and/or diuretics if needed to achieve BP target 1, 2
  • Consider non-steroidal mineralocorticoid receptor antagonists (finerenone) for persistent albuminuria despite ACE inhibitor therapy 1, 2
  • Consider steroidal mineralocorticoid receptor antagonists for resistant hypertension 1

Glycemic Control in Diabetic CKD

• SGLT2 Inhibitors: Recommended for patients with diabetes and CKD 1, 2
• GLP-1 Receptor Agonists: Consider for patients with diabetes as indicated 1, 2
• HbA1c Assessment: Twice-yearly for stable patients meeting treatment goals; quarterly for those with therapy changes or not meeting goals 1

Cardiovascular Risk Reduction

• Statin Therapy: Recommended for adults aged ≥50 years with CKD 1, 2
  • Consider statin/ezetimibe combination for enhanced LDL reduction 2
  • For patients 18-49 years, initiate statin if diabetes, prior cardiovascular disease, or 10-year CV risk >10% 2
• Antiplatelet Therapy: Low-dose aspirin for secondary prevention in established cardiovascular disease 1, 2

Management of CKD Complications

• Anemia:

  • Evaluate iron status before and during treatment 5
  • Administer supplemental iron when serum ferritin is <100 mcg/L or transferrin saturation <20% 5
  • Consider erythropoiesis-stimulating agents (ESAs) like darbepoetin alfa when hemoglobin <10 g/dL 5
  • Target hemoglobin <11 g/dL to avoid increased cardiovascular risks 5

• CKD-Mineral Bone Disorder (CKD-MBD):

  • Monitor and manage phosphate, calcium, PTH, and vitamin D levels 1

• Metabolic Acidosis:

  • Consider oral bicarbonate supplementation for serum bicarbonate <22 mmol/L 1, 3

• Potassium Abnormalities:

  • Monitor and manage hyperkalemia, particularly in patients on RAS inhibitors 1

Monitoring and Follow-up

• Regular Risk Assessment: Every 3-6 months 1, 2
• Medication Review: Adjust dosages based on eGFR changes and avoid nephrotoxic medications 6
• Complication Screening: Regular monitoring for anemia, metabolic acidosis, hyperphosphatemia, vitamin D deficiency, secondary hyperparathyroidism 6

Referral to Nephrology

• eGFR <30 mL/min/1.73 m² 2
• Albuminuria ≥300 mg/24 hours or proteinuria >1 g/day 2, 6
• Rapid decline in eGFR (>5 mL/min/1.73 m²/year) 2, 6
• Refractory hypertension (requiring ≥4 antihypertensive agents) 2
• Suspected hereditary kidney disease 2

Common Pitfalls and Caveats

• Attributing reduced eGFR to age alone: Always investigate for underlying causes of CKD 2
• Overreliance on HbA1c in advanced CKD: HbA1c may be less accurate in CKD stages G4-G5 1
• Protein restriction in vulnerable patients: Avoid protein restriction in malnourished, sarcopenic, or cachectic patients 1, 7
• Nephrotoxic medications: Avoid NSAIDs and other potential nephrotoxins 6
• Inadequate monitoring: Failure to adjust monitoring frequency based on risk category 2
• Delayed referral: Late referral to nephrology is associated with worse outcomes 2, 6