What is the recommended treatment for a patient with Chronic Kidney Disease (CKD)?

Treatment of Chronic Kidney Disease

The cornerstone of CKD management is a combination of renin-angiotensin system inhibitors (RASi), SGLT2 inhibitors, blood pressure control, and lifestyle modifications, with medication choices tailored to albuminuria status and eGFR. 1

First-Line Pharmacological Treatment

Renin-Angiotensin System Inhibitors (RASi)

• For patients with albuminuria:

  • Severely increased albuminuria (A3) without diabetes: Start ACEi or ARB (strong recommendation) 1
  • Moderately increased albuminuria (A2) without diabetes: Start ACEi or ARB (suggested) 1
  • Any albuminuria (A2 or A3) with diabetes: Start ACEi or ARB (strong recommendation) 1

• Administration guidelines:

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

SGLT2 Inhibitors

• Strong recommendations for:

  • Type 2 diabetes with eGFR ≥20 ml/min/1.73m² 1
  • eGFR ≥20 ml/min/1.73m² with ACR ≥200 mg/g 1
  • Heart failure patients regardless of albuminuria 1
  • Suggested for eGFR 20-45 ml/min/1.73m² with ACR <200 mg/g 1

• Administration guidelines:

  • Continue even if eGFR falls below 20 ml/min/1.73m² unless not tolerated 1
  • Withhold during prolonged fasting, surgery, or critical illness 1
  • Initial eGFR decrease is expected and not a reason to discontinue 1

Second-Line Therapies

Mineralocorticoid Receptor Antagonists (MRA)

• Consider nonsteroidal MRA for type 2 diabetes patients with:
  • eGFR >25 ml/min/1.73m²
  • Normal potassium
  • Persistent albuminuria despite maximum RASi dose 1
• May be added to RASi and SGLT2i combination 1
• Monitor potassium regularly after initiation 1

GLP-1 Receptor Agonists

• Recommended for type 2 diabetes with CKD who haven't achieved glycemic targets despite metformin and SGLT2i 1
• Prioritize agents with documented cardiovascular benefits 1

Blood Pressure Management

• Target BP for CKD patients:
  • Systolic BP range of 130-139 mmHg 1
  • For moderate-to-severe CKD with eGFR >30 ml/min/1.73m², target systolic BP of 120-129 mmHg if tolerated 1

Additional Management Strategies

Lipid Management

• For adults ≥50 years:

  • With eGFR <60 ml/min/1.73m²: Statin or statin/ezetimibe combination 1
  • With eGFR ≥60 ml/min/1.73m²: Statin therapy 1

• For adults 18-49 years with CKD:

  • Consider statin if coronary disease, diabetes, prior stroke, or 10-year CV risk >10% 1

Metabolic Acidosis

• Consider pharmacological treatment with or without dietary intervention 1

Hyperuricemia

• Treat symptomatic hyperuricemia 1
• Consider uric acid-lowering therapy after first gout episode 1
• Prefer xanthine oxidase inhibitors over uricosuric agents 1
• Do not use uric acid-lowering agents for asymptomatic hyperuricemia to delay CKD progression 1

Lifestyle Modifications

• Maintain protein intake of 0.8 g/kg body weight/day 2
• Restrict sodium to <2 g per day 2
• Consider Mediterranean-style diet 2
• Moderate physical activity for at least 150 minutes weekly 2
• Complete tobacco cessation 2

Monitoring and Follow-up

• Monitor eGFR and albuminuria based on risk category:

  • Low risk (G1A1, G2A1): Annual monitoring
  • Moderate risk (G1A2, G2A2, G3aA1): 1-2 times per year
  • High risk (G3aA3, G3bA2, G4, G5): 3-4 times per year 2

• After starting RASi:

  • Check BP, creatinine, and potassium within 2-4 weeks 1
  • Discontinue if creatinine rises >30% within 4 weeks 1

Common Pitfalls to Avoid

1. Inappropriate RASi discontinuation: Many clinicians stop RASi prematurely when creatinine rises slightly or mild hyperkalemia develops. Continue unless creatinine rises >30% or hyperkalemia is uncontrollable 1

2. Avoiding combination therapy: Using RASi, SGLT2i, and nonsteroidal MRA together (when appropriate) provides additive benefits for kidney protection 1, 2

3. Dual RAS blockade: Avoid any combination of ACEi, ARB, and direct renin inhibitors as this increases adverse effects without additional benefits 1

4. Underutilization of SGLT2i: These agents provide significant kidney protection even in non-diabetic CKD patients with albuminuria 1

5. Inadequate BP control: Failure to achieve target BP significantly accelerates CKD progression 1