What are the initial management guidelines for patients with Chronic Kidney Disease (CKD)?

Initial Management Guidelines for Chronic Kidney Disease (CKD)

The initial management of CKD should focus on blood pressure control, use of renin-angiotensin system inhibitors, cardiovascular risk reduction, and lifestyle modifications to slow disease progression and reduce mortality. 1, 2

Diagnosis and Risk Assessment

• Confirm CKD diagnosis by identifying persistent abnormalities in either:

  • eGFR <60 ml/min/1.73 m² and/or
  • Albuminuria ≥30 mg/24 hours (ACR ≥30 mg/g)
  • For >3 months 2

• Risk stratification using KDIGO heat map 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-A3, G4A1-A3, G5A1-A3 2

Blood Pressure Management

• Target blood pressure:

  • <140/90 mmHg for patients without albuminuria
  • <130/80 mmHg for patients with albuminuria (≥30 mg/24 hours) or diabetes 1, 2, 3

• First-line therapy:

  • ACE inhibitors or ARBs for patients with albuminuria >30 mg/day
  • Continue ACEi/ARB unless serum creatinine rises by more than 30% within 4 weeks 1, 2
  • Avoid combining ACEi, ARB, and direct renin inhibitors 2

• Lifestyle modifications for BP control:

  • Restrict dietary salt intake
  • Maintain healthy weight
  • Regular exercise
  • Moderate alcohol consumption
  • Complete smoking cessation 1, 2

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 eGFR ≥60 ml/min/1.73 m²: statin therapy 1
  • Adults 18-49 years with CKD: statin if coronary disease, diabetes, prior stroke, or 10-year CV risk >10% 1

• Antiplatelet therapy:

  • Low-dose aspirin for secondary prevention in patients with established cardiovascular disease 1, 2

Diabetes Management in CKD

• SGLT2 inhibitors:

  • First-line therapy for patients with type 2 diabetes and CKD with eGFR ≥20 mL/min/1.73 m²
  • Especially beneficial with albuminuria ≥200 mg/g creatinine 2

• Metformin:

  • First-line therapy if eGFR >30 ml/min/1.73 m² 2

Lifestyle Modifications

• Physical activity:

  • Moderate-intensity exercise for at least 150 minutes per week
  • Adjusted to cardiovascular and physical tolerance 2, 4

• Diet:

  • Plant-based "Mediterranean-style" diet
  • Protein intake of 0.8 g/kg body weight/day in adults with CKD G3-G5
  • Limit alcohol, meats, and high-fructose corn syrup intake 1, 2, 3

• Weight management:

  • Weight loss for overweight/obese patients
  • Consider referral to bariatric centers for morbidly obese adults with CKD 5

• Tobacco cessation:

  • Complete avoidance of all tobacco products 2

Medication Management

• Avoid nephrotoxic medications:

  • NSAIDs
  • Aminoglycosides
  • Amphotericin B 2, 6

• Adjust medication dosing based on eGFR:

  • Antibiotics
  • Oral hypoglycemic agents
  • NOACs (for atrial fibrillation) 1, 2

Monitoring and Follow-up

• Monitor eGFR and albuminuria based on risk category:

  • Low risk: Annual
  • Moderate risk: 1-2 times per year
  • High/very high risk: 3-4 times per year 2

• Monitor for CKD complications:

  • Hyperkalemia (especially with RAS inhibitors)
  • Metabolic acidosis (consider bicarbonate if <22 mmol/L)
  • Mineral bone disorders (phosphate, calcium, PTH, vitamin D)
  • Anemia (iron status, consider supplementation if ferritin <100 mcg/L or TSAT <20%) 2, 6

Additional Considerations

• Consider non-steroidal mineralocorticoid receptor antagonists (finerenone) if albuminuria persists despite ACE inhibitor therapy 2

• For symptomatic hyperuricemia/gout:

  • Xanthine oxidase inhibitors preferred over uricosuric agents
  • Low-dose colchicine or glucocorticoids for acute gout (avoid NSAIDs) 1

• For contrast studies:

  • IV fluids (isotonic saline or bicarbonate) 1 hour before and up to 6 hours after
  • Avoid gadolinium contrast in patients with eGFR <30 mL/min/1.73m² 2