What are the primary recommendations for managing Stage 1 Chronic Kidney Disease (CKD)?

Primary Recommendations for Managing Stage 1 Chronic Kidney Disease (CKD)

For Stage 1 CKD, implement a comprehensive treatment strategy focusing on lifestyle modifications, blood pressure control, and regular monitoring to prevent disease progression and reduce complications.

Diagnosis Confirmation and Risk Assessment

• Confirm CKD diagnosis by identifying persistent abnormalities in either urine albumin-to-creatinine ratio or eGFR for >3 months 1
• Evaluate albuminuria by measuring ACR in a random spot urine collection 1
• Use validated risk prediction models that incorporate eGFR and albuminuria to guide preventive therapies 1
• Monitor eGFR and albuminuria annually for low-risk patients (G1A1, G2A1) 1

Lifestyle Modifications

Physical Activity and Weight Management

• Undertake moderate-intensity physical activity for at least 150 minutes per week, adjusted to cardiovascular and physical tolerance 2, 1
• Avoid sedentary behavior 2
• Achieve optimal BMI (20-25 kg/m²) through weight loss for patients with obesity 2, 1

Dietary Recommendations

• Follow a plant-dominant, Mediterranean-style diet high in vegetables, fruits, whole grains, fiber, legumes, plant-based proteins, unsaturated fats, and nuts 2, 1
• Maintain protein intake of 0.8 g/kg/day 2, 1
• Restrict sodium intake to <2 g of sodium per day (<5 g salt/day) 2, 1
• Avoid processed meats, refined carbohydrates, and sweetened beverages 1
• Consult with renal dietitians for personalized dietary guidance 2

Tobacco Cessation

• Completely avoid tobacco products 2, 1
• Refer to smoking cessation programs as needed 1

Blood Pressure Management

• For patients with albuminuria, use ACE inhibitors or ARBs as first-line therapy 2, 1
• For patients without albuminuria, consider dihydropyridine calcium channel blockers or diuretics 2, 1
• Target blood pressure goal of <130/80 mmHg for patients with albuminuria ≥30 mg/24h 1
• Monitor serum creatinine and potassium within 2-4 weeks of ACEi/ARB 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

Glycemic Control (for patients with diabetes)

• Consider SGLT2 inhibitors as first-line therapy for T2D with CKD and eGFR ≥20 ml/min/1.73 m² 1
• Use metformin as first-line therapy if eGFR >45 mL/min/1.73m² 1
• Consider GLP-1 receptor agonists as second-line therapy for those who haven't achieved glycemic targets 1
• Monitor HbA1c twice yearly if stable, quarterly if therapy changes or not meeting targets 1

Lipid Management

• Use statins for adults ≥50 years with CKD 1
• Consider statin/ezetimibe combination for adults ≥50 years with eGFR <60 ml/min/1.73 m² 1

Monitoring and Follow-up

• Perform regular risk assessment every 3-6 months 1
• Schedule office visits every 3-6 months for BP assessment 1
• Monitor for and manage complications such as hyperkalemia, metabolic acidosis, and anemia 1
• Refer to nephrology with 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

Medication Considerations

• Avoid nephrotoxic medications, particularly NSAIDs 1
• Consider non-steroidal mineralocorticoid receptor antagonists (finerenone) if albuminuria persists despite ACE inhibitor therapy 1

Common Pitfalls to Avoid

• Do not attribute reduced eGFR to age alone; always investigate underlying causes 1
• Do not overrely on HbA1c in advanced CKD as it may be less accurate 1
• Do not restrict protein in malnourished, sarcopenic, or cachectic patients 1
• Do not discontinue ACEi/ARB when eGFR falls below 30 ml/min/1.73 m² unless serum creatinine rises significantly 1

Early identification and management of CKD Stage 1 is crucial as evidence suggests that progression to kidney failure can be delayed or prevented through appropriate interventions 3, 4. Primary care physicians play a vital role in early detection and management before complications develop 3.