What is the approach to managing Chronic Kidney Disease (CKD)?

Comprehensive Approach to Chronic Kidney Disease Management

The management of chronic kidney disease (CKD) requires a holistic approach that includes lifestyle modifications, 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 Monitoring

Diagnosis and Staging

• Confirm CKD diagnosis by identifying persistent abnormalities in either urine albumin-to-creatinine ratio (ACR) or eGFR for >3 months 1
• Use the KDIGO risk stratification system based on eGFR and albuminuria levels:
  • Low risk (green): G1A1, G2A1
  • Moderately elevated risk (yellow): G1A2, G2A2, G3aA1
  • High risk (orange): G1A3, G2A3, G3aA2, G3bA1
  • Very high risk (red): G3aA3, G3bA2, G3bA3, G4A1-A3, G5A1-A3 1

Monitoring Frequency

• Monitor eGFR and albuminuria based on risk category:
  • Low risk: Annual monitoring
  • Moderate risk: 1-2 times per year
  • High/very high risk: 3-4 times per year 1
• Regular risk assessment should be performed every 3-6 months 2
• Refer to nephrology when eGFR <30 mL/min/1.73 m², albuminuria ≥300 mg/24 hours, or rapid decline in eGFR (>5 mL/min/1.73 m²/year) 1

First-Line Interventions

Lifestyle Modifications

• Diet:

  • Follow a plant-dominant, Mediterranean-style diet high in vegetables, fruits, whole grains, fiber, legumes, and unsaturated fats 1
  • Maintain protein intake of 0.8 g/kg/day for non-dialysis CKD patients 1
  • Restrict sodium intake to <2 g of sodium per day (<5 g salt/day) 1
  • Avoid processed meats, refined carbohydrates, and sweetened beverages 1

• Physical Activity:

  • Engage in 150 minutes of moderate-intensity physical activity per week 1
  • Avoid sedentary behavior and aim for optimal BMI (20-25 kg/m²) 1

• Other Lifestyle Factors:

  • Complete tobacco cessation with referral to smoking cessation programs as needed 1
  • Weight management for patients with obesity 2

Pharmacological Management

Blood Pressure Control

• Target: <130/80 mmHg for patients with CKD, especially those with albuminuria ≥30 mg/24h 1
• First-line therapy: ACE inhibitors or ARBs for patients with albuminuria, titrated to the highest tolerated dose 1
  • Monitor serum creatinine and potassium within 2-4 weeks of initiation or dose increase 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
• Additional agents if needed:
  • Dihydropyridine calcium channel blockers and/or diuretics to achieve BP targets 2
  • Consider non-steroidal mineralocorticoid receptor antagonists (finerenone) if albuminuria persists despite ACE inhibitor therapy 1

Glycemic Control in Diabetic CKD

• First-line therapy:
  • SGLT2 inhibitors for T2D with CKD and eGFR ≥20 ml/min/1.73 m², continue even if eGFR falls below 20 ml/min/1.73 m² unless not tolerated 2
  • Metformin if eGFR >30 ml/min/1.73 m² 2
• Second-line therapy:
  • GLP-1 receptor agonists for T2D with CKD who haven't achieved glycemic targets despite metformin and SGLT2i 2
• Monitor HbA1c twice yearly if stable, quarterly if therapy changes or not meeting targets 1

Lipid Management

• Statins recommended for all adults with CKD, particularly:
  • Adults ≥50 years with eGFR <60 ml/min/1.73 m² (statin/ezetimibe combination)
  • Adults ≥50 years with CKD and eGFR ≥60 ml/min/1.73 m² 1

Management of Complications

Cardiovascular Risk Management

• Antiplatelet therapy with low-dose aspirin for secondary prevention in CKD with established cardiovascular disease 1
• Aggressive management of traditional cardiovascular risk factors 3

Metabolic Complications

• Monitor and manage phosphate, calcium, PTH, and vitamin D levels to prevent CKD-mineral bone disorder 1
• Consider oral bicarbonate supplementation for serum bicarbonate <22 mmol/L to manage metabolic acidosis 1
• Monitor and manage hyperkalemia, particularly in patients on RAS inhibitors 1
• Evaluate iron status and administer supplemental iron when serum ferritin is <100 mcg/L or transferrin saturation <20% 1

Common Pitfalls and Caveats

• Avoid nephrotoxic medications such as NSAIDs and consider alternative therapies 1, 4
• Do not discontinue ACEi/ARB when eGFR falls below 30 ml/min/1.73 m² unless there are specific contraindications 1
• Avoid overreliance on HbA1c in advanced CKD (stages G4-G5) as it may be less accurate 1
• Do not attribute reduced eGFR to age alone - always investigate for underlying causes of CKD 1
• Avoid protein restriction in malnourished, sarcopenic, or cachectic patients 1
• Monitor for side effects of losartan and other RAS inhibitors, including hyperkalemia, hypotension, and acute kidney injury 4

Multidisciplinary Team Approach

CKD management is optimized when care includes a multidisciplinary team to assist patients, including physicians, nurses, dietitians, pharmacists, and other healthcare professionals 2. This team-based approach ensures comprehensive care addressing all aspects of CKD management and associated comorbidities.