What is the recommended evaluation and treatment plan for a patient with suspected Chronic Kidney Disease (CKD)?

Recommended Evaluation and Treatment Plan for Suspected Chronic Kidney Disease (CKD)

The evaluation of suspected CKD should include assessment of GFR, albuminuria, and underlying causes, followed by risk-based treatment with SGLT2 inhibitors, RAS inhibitors, and statin therapy as the cornerstones of management. 1

Diagnostic Evaluation

Initial Assessment

1. Confirm CKD diagnosis:

   • Measure eGFR using CKD-EPI creatinine equation (without race variable) 2
   • Assess albuminuria using urine albumin-to-creatinine ratio (ACR)
   • Confirm abnormalities persist >3 months 3

2. CKD Definition:

   • GFR <60 ml/min/1.73 m² and/or
   • Albuminuria ≥30 mg/24 hours (or ACR ≥30 mg/g) 4

3. Additional Testing:

   • Serum cystatin C to confirm eGFR in uncertain cases 2
   • Consider exogenous filtration marker measurement when more accurate GFR is needed for treatment decisions 3

Comprehensive Evaluation

1. Determine CKD cause:

   • Clinical context assessment
   • Personal and family history
   • Social and environmental factors
   • Medication review
   • Physical examination
   • Laboratory measures
   • Imaging studies when indicated 3

2. Risk Stratification:

   • Classify by GFR category (G1-G5) and albuminuria category (A1-A3)
   • Use KDIGO heat map to assess risk:
     • Green (low risk): G1A1, G2A1
     • Yellow (moderate risk): G1A2, G2A2, G3aA1
     • Orange (high risk): G1A3, G2A3, G3aA2, G3bA1
     • Red (very high risk): G3aA3, G3bA2-A3, G4A1-A3, G5A1-A3 1

Treatment Plan

Lifestyle Modifications

1. Physical Activity:

   • 150 minutes of moderate-intensity activity weekly
   • Avoid sedentary behavior 1

2. Diet:

   • Plant-dominant, Mediterranean-style diet
   • Protein intake: 0.6-0.8 g/kg/day for CKD G3
   • Sodium restriction: <2 g/day (<5 g sodium chloride/day) 3, 1
   • Consider referral to renal dietitian for individualized plan 1

3. Smoking Cessation:

   • Complete avoidance of tobacco products
   • Referral to smoking cessation programs 1

Pharmacological Management

1. Blood Pressure Control:

   • Target: <120 mmHg systolic when tolerated using standardized office BP measurement 3
   • First-line agents:
     • ACE inhibitors or ARBs for patients with albuminuria 3, 1
     • Use highest approved tolerable dose 3
   • Monitor serum creatinine and potassium 2-4 weeks after initiation or dose increase 3
   • Continue ACEi/ARB unless serum creatinine rises >30% within 4 weeks 3

2. Glycemic Control in Diabetes:

   • SGLT2 inhibitors:

     • Recommended for T2D with CKD and eGFR ≥20 ml/min/1.73 m² 3
     • Continue even if eGFR falls below 20 ml/min/1.73 m² unless not tolerated 3
     • Withhold during prolonged fasting, surgery, or critical illness 3

   • GLP-1 receptor agonists:

     • Recommended for T2D with CKD who haven't achieved glycemic targets despite metformin and SGLT2i 3
     • Prioritize agents with documented cardiovascular benefits 3

3. Albuminuria Management:

   • RAS inhibitors (ACEi or ARB):

     • Recommended for CKD with severely increased albuminuria (A3) without diabetes 3
     • Recommended for CKD with moderately-to-severely increased albuminuria (A2-A3) with diabetes 3
     • Suggested for CKD with moderately increased albuminuria (A2) without diabetes 3

   • Nonsteroidal MRA (e.g., finerenone):

     • Consider for T2D with eGFR >25 ml/min/1.73 m², normal potassium, and persistent albuminuria despite RASi 3
     • May be added to RASi and SGLT2i 3
     • Monitor potassium regularly after initiation 3

4. Cardiovascular Risk Reduction:

   • Statins:

     • Recommended for adults ≥50 years with eGFR <60 ml/min/1.73 m² (statin/ezetimibe combination) 3
     • Recommended for adults ≥50 years with CKD and eGFR ≥60 ml/min/1.73 m² 3

   • Antiplatelet therapy:

     • Low-dose aspirin recommended for secondary prevention in CKD with established cardiovascular disease 3

5. Metabolic Complication Management:

   • Acidosis: Consider pharmacological treatment for serum bicarbonate <18 mmol/l 3
   • Hyperkalemia: Implement individualized approach with dietary and pharmacologic interventions 3
   • Hyperuricemia: Treat symptomatic hyperuricemia with xanthine oxidase inhibitors 3

Monitoring Plan

1. Frequency based on risk category:

   • G1-G2, A1: Annual
   • G3a, A1 or G1-G2, A2: 1-2 times per year
   • G4-G5, A1-A3 or Any GFR, A3: 3-4 times per year 1

2. Parameters to monitor:

   • eGFR and albuminuria
   • Blood pressure
   • Serum potassium and bicarbonate
   • Phosphate, calcium, PTH, and vitamin D levels
   • Iron status 1

Nephrology Referral Criteria

Refer to nephrology for:

• eGFR <30 ml/min/1.73 m²
• Albuminuria ≥300 mg/24 hours
• Rapid decline in eGFR (>5 ml/min/1.73 m²/year) 1, 4

Common Pitfalls to Avoid

1. Attributing reduced eGFR to age alone without investigating underlying causes 1
2. Overreliance on HbA1c in advanced CKD (stages G4-G5) 1
3. Protein restriction in malnourished, sarcopenic, or cachectic patients 1
4. Use of nephrotoxic medications (e.g., NSAIDs) 1, 4
5. Combining ACEi, ARB, and direct renin inhibitors 3
6. Discontinuing ACEi/ARB when eGFR falls below 30 ml/min/1.73 m² 3
7. Failing to monitor for complications of CKD (hyperkalemia, metabolic acidosis, hyperphosphatemia) 4

By following this comprehensive evaluation and treatment approach, you can effectively manage CKD, slow disease progression, and reduce the risk of cardiovascular complications and mortality.