What are the management strategies for Chronic Kidney Disease (CKD)?

Management Strategies for Chronic Kidney Disease (CKD)

The management of chronic kidney disease requires a comprehensive approach focused on blood pressure control with ACE inhibitors or ARBs, SGLT2 inhibitors for diabetic kidney disease, lifestyle modifications, and regular monitoring of kidney function to reduce mortality and slow disease progression. 1

Risk Assessment and Classification

• Confirm CKD diagnosis by identifying persistent abnormalities in either urine albumin-to-creatinine ratio or eGFR for >3 months 1
• Use the KDIGO heat map to categorize risk 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

First-Line Pharmacological Therapy

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
• First-line medications:
  • ACE inhibitors or ARBs for patients with albuminuria >30 mg/day
  • Continue unless serum creatinine rises by more than 30% within 4 weeks 1

Diabetic Kidney Disease Management

• SGLT2 inhibitors are first-line therapy for patients with type 2 diabetes and CKD with eGFR ≥20 mL/min/1.73 m² 1
• Metformin is recommended if eGFR >30 ml/min/1.73 m² 1
• Optimize glycemic control to slow CKD progression 2

Cardiovascular Risk Reduction

Statin Therapy

• Statin therapy for:
  • Adults ≥50 years with eGFR <60 ml/min/1.73 m²
  • Adults ≥50 years with eGFR ≥60 ml/min/1.73 m² (statin or statin/ezetimibe combination)
  • Adults 18-49 years with CKD who have 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

Lifestyle Modifications

Diet

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

Physical Activity

• Moderate-intensity physical activity for at least 150 minutes per week 1
• Walking programs can help slow CKD progression 3
• Adjust exercise intensity based on cardiovascular and physical tolerance 1

Weight Management

• Maintain healthy weight 1
• For obese CKD patients, weight loss interventions may provide renal and cardiovascular benefits 4
• Consider referral to bariatric centers for morbidly obese adults with CKD 4

Smoking Cessation

• Complete smoking cessation is essential as tobacco use accelerates CKD progression 1, 3

Medication Management

Avoid Nephrotoxins

• Avoid nephrotoxic medications including:
  • NSAIDs
  • Aminoglycosides
  • Amphotericin B 1

Medication Dosing Adjustments

• Adjust medication dosing based on eGFR for:
  • Antibiotics
  • Oral hypoglycemic agents
  • NOACs (for atrial fibrillation) 1

Contrast Studies Precautions

• Consider reducing or holding CNI therapy pre- and post-contrast exposure
• Administer IV fluids (isotonic saline or bicarbonate) 1 hour before and up to 6 hours after contrast studies
• Avoid gadolinium contrast in patients with eGFR <30 mL/min/1.73m² 1

Management of CKD Complications

Mineral and Bone Disorder

• Monitor and manage phosphate, calcium, PTH, and vitamin D levels 1
• Consider oral bicarbonate supplementation for serum bicarbonate <22 mmol/L 1

Anemia and Iron Management

• Evaluate iron status before and during treatment
• Administer supplemental iron when serum ferritin is <100 mcg/L or transferrin saturation <20% 1

Hyperuricemia/Gout

• Xanthine oxidase inhibitors are preferred over uricosuric agents
• For acute gout, use low-dose colchicine or glucocorticoids (avoid NSAIDs) 1

Monitoring and Follow-up

• Monitor eGFR and albuminuria regularly based on risk category:
  • G1-G2 A1: Annual
  • G3a A1 or G1-G2 A2: 1-2 times per year
  • G4-G5 A1-A3 or Any A3: 3-4 times per year 1
• Quantitatively assess urinary albumin and eGFR at least annually in all patients with diabetes 1

Symptom Management

• Regularly assess symptoms using validated tools (ESAS-r:Renal or POS-renal) 1
• Address common symptoms:
  • Pain/discomfort
  • Fatigue
  • Sleep problems
  • Itching/skin problems
  • Depressive symptoms
  • Restless legs syndrome 1
• Use loop diuretics at optimal doses to maintain volume control 1
• Consider hospice referral when estimated prognosis is 6 months or less 1

When to Refer to a Nephrologist

• High risk of CKD progression (eGFR <30 mL/min/1.73 m², albuminuria ≥300 mg per 24 hours, or rapid decline in eGFR) 5
• Complex management issues or complications not responding to standard therapy

Common Pitfalls to Avoid

• Failing to confirm CKD diagnosis with persistent abnormalities for >3 months
• Overlooking albuminuria assessment in risk stratification
• Continuing ACE inhibitors/ARBs when serum creatinine rises >30% within 4 weeks of initiation
• Using nephrotoxic medications in CKD patients
• Not adjusting medication doses based on eGFR
• Neglecting regular monitoring of kidney function and complications