Best Initial Medications for Chronic Kidney Disease (CKD)
Renin-angiotensin system inhibitors (ACE inhibitors or ARBs) are the first-line medications for most patients with CKD, especially those with albuminuria or hypertension, as they reduce both cardiovascular events and kidney disease progression. 1
First-Line Medication Selection Based on Patient Characteristics
Patients with Hypertension and CKD:
For CKD patients with severely increased albuminuria (category A3) without diabetes: Start with an ACE inhibitor or ARB as first-line therapy 1
For CKD patients with moderately increased albuminuria (category A2) without diabetes: Start with an ACE inhibitor or ARB 1
For CKD patients with moderately to severely increased albuminuria (categories A2 and A3) with diabetes: Start with an ACE inhibitor or ARB 1
For CKD patients without significant albuminuria: Any first-line BP-lowering agent can be used, including thiazide diuretics, ACE inhibitors, ARBs, or calcium channel blockers (CCBs) 1
For Black patients with CKD: Initial therapy should be a thiazide-type diuretic or calcium channel blocker. If the patient has proteinuria, an ACE inhibitor or ARB should be used 1
Blood Pressure Targets:
Target systolic blood pressure <120 mmHg for most CKD patients to reduce cardiovascular risk and mortality 1
For patients with advanced CKD (stages 4-5), evidence for intensive BP targets is less robust, and individualized targets may be needed 1
Additional Important Medications for CKD Management
Lipid Management:
For adults ≥50 years with eGFR <60 ml/min/1.73 m²: Start statin or statin/ezetimibe combination 1
For adults ≥50 years with CKD and eGFR ≥60 ml/min/1.73 m²: Start statin therapy 1
For adults 18-49 years with CKD: Consider statin therapy if they have coronary disease, diabetes, prior stroke, or elevated cardiovascular risk 1
Hyperkalemia Management:
- For CKD patients with hyperkalemia who need to continue RAAS inhibitors, consider potassium binders such as sodium zirconium cyclosilicate or patiromer 2, 3
Medication Combinations and Special Considerations
Multiple medications are often required to achieve target blood pressure in CKD patients 1
Avoid simultaneous use of ACE inhibitor, ARB, and/or renin inhibitor combinations as this increases risk of hyperkalemia and acute kidney injury without additional benefit 1
Thiazide diuretics (especially chlorthalidone) can be effective even in advanced CKD (eGFR <30 ml/min/1.73 m²), contrary to common belief 1
Loop diuretics may be needed for volume control in advanced CKD or nephrotic-range proteinuria 1
For CKD patients with atrial fibrillation: Non-vitamin K antagonist oral anticoagulants (NOACs) are preferred over vitamin K antagonists, with appropriate dose adjustment for GFR 1
Common Pitfalls and Caveats
Monitoring for adverse effects is essential when using RAAS inhibitors, including checking for hyperkalemia, hypotension, and acute kidney injury 4
Initial decline in eGFR (up to 30%) after starting RAAS inhibitors is expected and not a reason to discontinue therapy unless severe or persistent 1
Sodium restriction enhances the efficacy of RAAS inhibitors and may be preferable to dual RAAS blockade 4
Medication adherence is often lower in CKD patients, particularly those with advanced disease, requiring additional monitoring and support 5
Dihydropyridine CCBs should not be used as monotherapy in proteinuric CKD patients but always in combination with a RAAS blocker 6
For kidney transplant recipients with hypertension, calcium channel antagonists may be preferred due to improved GFR and kidney survival 1
By following these evidence-based recommendations and considering individual patient factors, appropriate medication selection can help slow CKD progression, reduce cardiovascular risk, and improve overall outcomes 7, 8.