What are the key recommendations for managing patients with kidney disease?

Key Recommendations for Managing Patients with Kidney Disease

The cornerstone of chronic kidney disease (CKD) management includes optimizing glucose and blood pressure control, using ACE inhibitors or ARBs for patients with albuminuria, regular monitoring of kidney function, and timely referral to nephrology specialists for advanced disease or complications.

Diagnosis and Screening

• Confirm CKD diagnosis by identifying persistent abnormalities in either urine albumin-to-creatinine ratio (UACR) or eGFR for >3 months 1
• Screen for CKD in high-risk populations:
  • At least annual UACR and eGFR assessment in patients with type 1 diabetes duration ≥5 years and all patients with type 2 diabetes 2
  • Annual screening for patients at high risk (African Americans, CD4+ <200 cells/mL, HIV RNA >14,000 copies/mL, diabetes, hypertension, or HCV coinfection) 2
• Use the CKD-EPI equation for estimating GFR in routine practice 3
• Classify CKD using the KDIGO heat map based on eGFR and albuminuria levels to guide management decisions 1

Blood Pressure Management

• Optimize blood pressure control to reduce risk or slow CKD progression 2
• Target blood pressure:
  • <140/90 mmHg for patients without albuminuria 1
  • <130/80 mmHg for patients with albuminuria (UACR ≥30 mg/g) 1
• Use ACE inhibitors or ARBs as first-line therapy for patients with albuminuria:
  • ACE inhibitor or ARB is suggested for non-pregnant patients with modestly elevated urinary albumin excretion (30-299 mg/day) 2
  • ACE inhibitor or ARB is strongly recommended for those with urinary albumin excretion >300 mg/day 2
• Monitor serum creatinine and potassium within 2-4 weeks of initiation or dose increase of ACE inhibitors, ARBs, or diuretics 2, 1
• Continue ACEi/ARB unless serum creatinine rises by more than 30% within 4 weeks 1
• Do not use ACEi and ARB together or with direct renin inhibitors 1

Glycemic Control

• Optimize glucose control to reduce risk or slow progression of diabetic kidney disease 2
• Consider metformin as first-line therapy if eGFR >45 mL/min/1.73m² 1
• Consider SGLT2 inhibitors for type 2 diabetes with CKD and eGFR ≥20 ml/min/1.73 m² 1
• Monitor HbA1c twice yearly if stable, quarterly if therapy changes or not meeting targets 1

Lifestyle Modifications

• Restrict sodium intake to <2 g of sodium per day (<5 g salt/day) 2, 1
• Maintain protein intake of 0.8 g/kg/day for patients with CKD not on dialysis 1
• Avoid protein restriction in malnourished patients 1
• Engage in 150 minutes of moderate-intensity physical activity per week 1
• Follow a plant-dominant, Mediterranean-style diet high in vegetables, fruits, whole grains, fiber, legumes, plant-based proteins, unsaturated fats, and nuts 1
• Complete avoidance of tobacco products with referral to smoking cessation programs as needed 1

Monitoring and Follow-up

• Monitor eGFR and albuminuria regularly based on risk category:
  • Low risk (G1A1, G2A1): Annual monitoring
  • Moderate risk (G3aA1, G1A2, G2A2): 1-2 times per year
  • High risk (G3bA1, G3aA2, G1A3, G2A3): 2-3 times per year
  • Very high risk (G4-G5, any A3): 3-4 times per year 1
• When eGFR is <60 mL/min/1.73 m², evaluate and manage potential complications of CKD 2
• Continue monitoring UACR in patients with albuminuria to assess progression 2

Referral to Nephrology

• Consider referral to a nephrologist when:
  • eGFR <30 mL/min/1.73 m² 1
  • Albuminuria ≥300 mg/24 hours 1
  • Rapid decline in eGFR (>5 mL/min/1.73 m²/year) 1
  • Uncertainty about etiology of kidney disease 2
  • Difficult management issues 2
  • Advanced kidney disease 2

Additional Pharmacological Management

• Consider non-steroidal mineralocorticoid receptor antagonists (finerenone) if albuminuria persists despite ACE inhibitor therapy 1
• Prescribe statins for adults ≥50 years with eGFR <60 ml/min/1.73 m² (statin/ezetimibe combination) 1
• Consider oral bicarbonate supplementation for serum bicarbonate <22 mmol/L to manage metabolic acidosis 1
• Evaluate iron status and administer supplemental iron when serum ferritin is <100 mcg/L or transferrin saturation <20% 1

Avoiding Harmful Interventions

• Do not use ACE inhibitor or ARB for primary prevention of diabetic kidney disease in patients with diabetes who have normal blood pressure and normal UACR (<30 mg/g) 2
• Avoid nephrotoxic medications, such as NSAIDs 1, 4
• Avoid calcium channel blockers in patients receiving protease inhibitors (for HIV patients) 2
• Do not reduce dietary protein below the recommended daily allowance of 0.8 g/kg/day as it does not alter glycemic measures, cardiovascular risk measures, or the course of GFR decline 2

Special Populations: HIV Patients

• Patients with HIV-associated nephropathy (HIVAN) should be treated with HAART at diagnosis 2
• HAART should not be withheld from patients simply because of the severity of their renal dysfunction 2
• Addition of ACE inhibitors or ARBs should be considered in treating both adult and pediatric patients with HIVAN if HAART alone does not result in improvement of renal function 2

By implementing these evidence-based recommendations, clinicians can effectively manage patients with kidney disease, slow disease progression, and reduce the risk of complications and mortality.