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

Management Strategies for Chronic Kidney Disease (CKD)

The most effective management of chronic kidney disease requires a comprehensive approach including ACE inhibitors/ARBs, SGLT2 inhibitors for diabetic patients, lifestyle modifications, and careful monitoring of complications to slow disease progression and reduce mortality. 1

Pharmacological Interventions

First-Line Medications

• ACE inhibitors or ARBs:

  • Recommended for patients with albuminuria >30 mg/day 1
  • Continue unless serum creatinine rises by more than 30% within 4 weeks
  • Note: ARBs like losartan may cause fewer side effects like cough compared to ACE inhibitors 2

• SGLT2 inhibitors:

  • First-line for patients with type 2 diabetes and CKD with eGFR ≥20 mL/min/1.73 m² 1
  • Especially beneficial with albuminuria ≥200 mg/g creatinine
  • Shown to reduce CKD progression and cardiovascular events 3

• Finerenone:

  • Non-steroidal mineralocorticoid receptor antagonist
  • Reduces CKD progression, cardiovascular risks, and mortality in diabetic kidney disease 1

Other Important Medications

• Metformin: First-line therapy if eGFR >30 ml/min/1.73 m² 1
• Statins:
  • Recommended for adults ≥50 years with eGFR <60 ml/min/1.73 m² 1
  • Statin or statin/ezetimibe combination for adults ≥50 years with eGFR ≥60 ml/min/1.73 m² 1
  • For adults 18-49 years with CKD, use statins if there is coronary disease, diabetes, prior stroke, or 10-year CV risk >10% 1

Blood Pressure Management

• Target blood pressure:

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

• Strategies:

  • First-line: ACE inhibitors or ARBs
  • Add SGLT2 inhibitors in diabetic kidney disease
  • Implement lifestyle modifications including reduced sodium intake

Lifestyle Modifications

• Diet:

  • Adopt plant-based diets over animal-based foods 1
  • Maintain protein intake of 0.8 g/kg body weight/day in adults with CKD G3-G5 1
  • Restrict dietary salt intake 1

• Physical Activity:

  • Undertake moderate-intensity physical activity for at least 150 minutes per week 1, 4
  • Adjust based on cardiovascular and physical tolerance
  • Regular exercise helps attenuate decline in renal function and improves cardiovascular risk markers 4

• Other Modifications:

  • Maintain healthy weight 1
  • Completely avoid tobacco products 1
  • Moderate alcohol consumption (avoid binge drinking) 3

Monitoring and Diagnosis

• Regular Assessment:

  • Quantitatively assess urinary albumin (e.g., urine albumin-to-creatinine ratio) and eGFR at least annually 1
  • Confirm CKD diagnosis by identifying persistent abnormalities for >3 months 1

• Monitoring Frequency 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 GFR with A3: 3-4 times per year 1

Management of Complications

Mineral and Bone Disorder

• Monitor phosphate, calcium, PTH, and vitamin D levels 1
• Consider oral bicarbonate supplementation for serum bicarbonate <22 mmol/L 1, 5

Anemia Management

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

Symptom Management

• Regularly assess symptoms using validated tools (ESAS-r:Renal or POS-renal) 1
• Address common symptoms:
  • Pain/discomfort
  • Fatigue/lack of energy
  • Sleep problems
  • Itching/skin problems
  • Depressive symptoms
  • Restless legs syndrome 1
• Use loop diuretics at optimal doses to maintain volume control 1

Patient-Centered Care

• Perform shared decision-making to understand patient's values and goals 1
• Document patient's decisions in advance directives as appropriate 1
• Consider hospice referral when estimated prognosis is 6 months or less 1

Pitfalls and Caveats

• Monitor for hyperkalemia when using ACE inhibitors, ARBs, or finerenone
• Watch for acute kidney injury when initiating SGLT2 inhibitors
• Be cautious with NSAIDs as they can worsen kidney function 2
• Adjust medication dosages according to eGFR 6
• Monitor for side effects of losartan including dizziness, hypotension, hyperkalemia, and rarely angioedema 2
• Ensure regular monitoring of kidney function in patients on multiple CKD medications

By implementing these evidence-based strategies, CKD progression can be slowed, complications reduced, and patient quality of life improved.