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 significant albuminuria. 1

Blood Pressure Management

Blood pressure control is a cornerstone of CKD management:

• Target blood pressure goals:

  • For patients with albuminuria <30 mg/24h: ≤140/90 mmHg 1
  • For patients with albuminuria ≥30 mg/24h: ≤130/80 mmHg 1

• First-line antihypertensive therapy:

  • For patients with albuminuria ≥30 mg/24h: ACEi or ARB 1
  • For Black patients: Thiazide diuretic or calcium channel blocker 2, 1
  • For non-Black patients: ACEi, ARB, thiazide diuretic, or calcium channel blocker 2, 1

• RASi dosing and monitoring:

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

Cardiovascular Risk Reduction

• Statin therapy:

  • Adults ≥50 years with CKD and 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 therapy 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

SGLT2 Inhibitor Therapy

• Add SGLT2 inhibitor for patients with type 2 diabetes and eGFR ≥20 ml/min/1.73 m² 1
• Add SGLT2 inhibitor for patients with eGFR ≥20 ml/min/1.73 m² and ACR ≥200 mg/g 1

Lifestyle Modifications

• Smoking cessation 1
• Mediterranean-style diet 1
• Sodium restriction (<2g/day) 1
• Maintain healthy body weight (BMI 20-25 kg/m²) 1
• Regular exercise (30 minutes, 5 times weekly) 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 1
• Evaluate iron status before and during treatment if anemia is present 3
• Consider supplemental iron therapy when serum ferritin is <100 mcg/L or transferrin saturation is <20% 3

Important Precautions and Contraindications

• Avoid combination therapy with ACEi and ARB as this is harmful 1
• Do not discontinue RASi for minor increases in serum creatinine (≤30%) in the absence of volume depletion 1
• Consider the risk of acute kidney injury with procedures and medications 1
• Avoid frequent dose adjustments of ESA therapy if used for anemia 3

When to Refer to Nephrology

Patients at high risk of CKD progression should be promptly referred to a nephrologist, including those with:

• eGFR <30 mL/min/1.73 m² 4
• Albuminuria ≥300 mg per 24 hours 4
• Rapid decline in eGFR 4

The management of CKD requires a multidisciplinary approach involving primary care physicians, nephrologists, endocrinologists, cardiologists, and dietitians to address the complex needs of these patients 1.