What is the initial management for patients with chronic kidney disease?

Initial Management of Chronic Kidney Disease

The initial management of chronic kidney disease should focus on blood pressure control with renin-angiotensin system inhibitors (ACEi or ARB), cardiovascular risk reduction with statins, and SGLT2 inhibitors for patients with type 2 diabetes or albuminuria >200 mg/g. 1, 2

Blood Pressure Management

Target Blood Pressure

• For patients with albuminuria <30 mg/24h: Target BP ≤140/90 mmHg 2
• For patients with albuminuria ≥30 mg/24h: Target BP ≤130/80 mmHg 2
• For children with CKD: Target mean arterial pressure ≤50th percentile for age, sex, and height 1

Antihypertensive Therapy

1. First-line therapy:

   • For patients with albuminuria ≥30 mg/24h: ACEi or ARB 1, 2
   • For patients without albuminuria: ACEi, ARB, thiazide diuretic, or calcium channel blocker 2

2. RASi dosing and monitoring:

   • Use highest approved dose that is tolerated 1
   • Check serum creatinine and potassium within 2-4 weeks of initiation or dose increase 1
   • Continue therapy unless serum creatinine rises by >30% within 4 weeks 1
   • Continue RASi even when eGFR falls below 30 ml/min/1.73 m² 1

Cardiovascular Risk Reduction

Statin Therapy

• Adults ≥50 years with eGFR <60 ml/min/1.73 m²: Statin or statin/ezetimibe combination 1
• Adults ≥50 years with CKD and eGFR ≥60 ml/min/1.73 m²: Statin 1
• Adults 18-49 years with CKD: Consider statin if they have coronary disease, diabetes, prior stroke, or 10-year cardiovascular risk >10% 1

Antiplatelet Therapy

• Low-dose aspirin for secondary prevention in patients with established cardiovascular disease 1
• Consider P2Y12 inhibitors when aspirin is not tolerated 1

Management of Albuminuria

For patients without diabetes:

• Severely increased albuminuria (>300 mg/g): Start ACEi or ARB (strong recommendation) 1
• Moderately increased albuminuria (30-300 mg/g): Consider ACEi or ARB 1

For patients with diabetes:

• Moderately-to-severely increased albuminuria (≥30 mg/g): Start ACEi or ARB 1
• Type 2 diabetes with eGFR ≥20 ml/min/1.73 m²: Add SGLT2 inhibitor 1
• For patients with eGFR ≥20 ml/min/1.73 m² and ACR ≥200 mg/g: Add SGLT2 inhibitor 1

Additional Pharmacotherapy

SGLT2 Inhibitors

• Continue SGLT2i even if eGFR falls below 20 ml/min/1.73 m² unless not tolerated or kidney replacement therapy is initiated 1
• Withhold during times of prolonged fasting, surgery, or critical illness 1

Nonsteroidal Mineralocorticoid Receptor Antagonists

• Consider for adults with T2D, eGFR >25 ml/min/1.73 m², normal potassium, and persistent albuminuria despite maximum tolerated RASi 1
• Monitor serum potassium regularly after initiation 1

Lifestyle Modifications

• Sodium restriction (<2g/day) 2
• Maintain healthy body weight (BMI 20-25 kg/m²) 2
• Regular exercise (30 minutes, 5 times weekly) 2
• Smoking cessation 1, 2
• Consider Mediterranean-style diet 1
• Dietary protein intake should be maximum 0.8 g/kg body weight per day for non-dialysis CKD stage 3 or higher 1

Monitoring and Follow-up

• Check serum creatinine and potassium within 2-4 weeks of RASi initiation or dose increase 1
• Annual monitoring of kidney function and albuminuria for stable patients 2
• For patients on erythropoietin therapy: Monitor hemoglobin weekly until stable, then monthly 3

Common Pitfalls and Caveats

1. Do not discontinue RASi for minor increases in serum creatinine (≤30%) in the absence of volume depletion 1

2. Avoid combination therapy with ACEi and ARB as this is harmful and should be avoided in patients with CKD 1

3. Be cautious with contrast media in advanced CKD as it temporarily reduces eGFR 4

4. Consider the age of the patient when applying guidelines, as evidence for ACEi/ARB use has limited relevance to most persons older than 70 years 5

5. Recognize that multimorbidity is common in CKD patients and may require multidisciplinary management involving primary care physicians, nephrologists, endocrinologists, cardiologists, and dietitians 1