Initial Management of Chronic Kidney Disease
The initial management of chronic kidney disease (CKD) should focus on a comprehensive treatment strategy targeting blood pressure control, lifestyle modifications, and appropriate medication use to reduce the risk of CKD progression and associated complications.1
Blood Pressure Management
- Use standardized blood pressure measurement techniques for accurate assessment, as the recommended targets are based on standardized measurements 1
- Target systolic blood pressure <120 mmHg in adults with high blood pressure and CKD, when tolerated 1
- For patients who cannot tolerate lower targets, maintain blood pressure <140/90 mmHg in those without albuminuria and <130/80 mmHg in those with albuminuria 2
- Initiate renin-angiotensin system inhibitors (RASi) as first-line therapy:
- For patients with high BP, CKD, and severely increased albuminuria (G1-G4, A3) without diabetes 1
- For patients with high BP, CKD, and moderately increased albuminuria (G1-G4, A2) without diabetes 1
- For patients with high BP, CKD, and moderately-to-severely increased albuminuria (G1-G4, A2 and A3) with diabetes 1
- Avoid any combination of ACEi, ARB, and direct renin inhibitor (DRI) therapy 1
- Consider adding a diuretic if blood pressure is not controlled with RASi alone 3
Lifestyle Interventions
- Recommend dietary sodium restriction to <2 g of sodium per day (<5 g of sodium chloride per day) 1
- Advise moderate-intensity physical activity for at least 150 minutes per week, adjusted to cardiovascular and physical tolerance 1
- Encourage patients to achieve and maintain optimal body mass index and avoid sedentary behavior 1, 2
- Consider a plant-based "Mediterranean-style" diet to reduce cardiovascular risk 1
- Discourage tobacco use and provide smoking cessation resources 1, 4
Cardiovascular Risk Management
- Prescribe statins based on age and cardiovascular risk:
- For adults ≥50 years with eGFR <60 ml/min/1.73m², use statin or statin/ezetimibe combination 1
- For adults ≥50 years with CKD and eGFR ≥60 ml/min/1.73m², use 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
- Recommend low-dose aspirin for secondary prevention in patients with established cardiovascular disease 1
Diabetes Management in CKD
- Optimize glycemic control in patients with diabetes to slow CKD progression 1, 2
- Consider SGLT2 inhibitors for patients with type 2 diabetes and CKD who have not reached glycemic goals 4
- Use a multidisciplinary approach involving diabetes care specialists, dietitians, and other healthcare professionals 1
Monitoring and Risk Assessment
- Use validated risk prediction models to estimate progression to kidney failure 1, 4
- Consider referral to nephrology for patients with advanced CKD (GFR <30 ml/min/1.73m²), rapidly declining kidney function, or significant albuminuria 5, 4
- Monitor kidney function regularly and adjust medication dosages as needed 3, 4
- Avoid nephrotoxic medications and adjust dosing of renally cleared medications 4, 6
Management of CKD Complications
- Treat symptomatic hyperuricemia with uric acid-lowering therapy, preferring xanthine oxidase inhibitors 1
- Do not use uric acid-lowering agents for asymptomatic hyperuricemia to delay CKD progression 1
- For patients with atrial fibrillation, use non-vitamin K antagonist oral anticoagulants (NOACs) in preference to warfarin for CKD G1-G4, with appropriate dose adjustments 1
Pitfalls and Caveats
- Standardized blood pressure measurement is critical; routine office measurements may lead to inappropriate treatment decisions 1
- RASi may cause acute kidney injury, hyperkalemia, or cough; monitor kidney function and electrolytes after initiation 7
- Avoid NSAIDs when possible due to risk of acute kidney injury and CKD progression 1, 4
- Intravenous iodinated contrast media should be avoided in advanced CKD due to risk of contrast-induced nephropathy 4
- Be cautious with NOAC dosing in advanced CKD (G4-G5), as dose adjustments are required based on GFR 1