What are the management and treatment options for Chronic Kidney Disease (CKD)?

Management and Treatment Options for Chronic Kidney Disease (CKD)

The management of chronic kidney disease requires a comprehensive treatment strategy focused on slowing disease progression, managing complications, and improving quality of life through lifestyle modifications, dietary interventions, blood pressure control, and specific pharmacological therapies. 1

Risk Assessment and Referral

• Use externally validated risk equations to estimate the absolute risk of kidney failure in people with CKD G3-G5 to guide clinical decision-making 1
• Consider nephrology referral when 5-year kidney failure risk is 3-5% 1
• Initiate multidisciplinary care when 2-year kidney failure risk exceeds 10% 1
• Begin preparation for kidney replacement therapy when 2-year kidney failure risk exceeds 40% 1
• For cardiovascular risk assessment, use validated models that incorporate eGFR and albuminuria 1

Lifestyle Modifications

Physical Activity

• Recommend moderate-intensity physical activity for at least 150 minutes per week, adjusted to individual cardiovascular and physical tolerance 1
• Advise against sedentary behavior and tailor exercise recommendations based on age, ethnicity, comorbidities, and fall risk 1
• For those at higher risk of falls, provide specific guidance on exercise intensity (low, moderate, or vigorous) and type (aerobic vs. resistance) 1

Weight Management

• Encourage weight loss in overweight or obese patients with CKD 1
• Weight loss can slow CKD progression and improve cardiovascular outcomes 2

Smoking Cessation

• Advise complete abstinence from tobacco products as smoking increases the risk of CKD progression 3, 4
• Provide referrals to smoking cessation programs when available 1

Dietary Interventions

• Recommend diets with higher consumption of plant-based foods compared to animal-based foods and lower consumption of ultraprocessed foods 1
• Suggest maintaining protein intake of 0.8 g/kg body weight/day in adults with CKD G3-G5 1
• Avoid high protein intake (>1.3 g/kg body weight/day) in adults with CKD at risk of progression 1
• Consult with renal dietitians to provide individualized dietary guidance regarding sodium, phosphorus, potassium, and protein intake 1
• Consider adherence to Mediterranean-style diets which may slow CKD progression 2

Blood Pressure Management

• Target blood pressure <140/90 mmHg in patients without albuminuria and <130/80 mmHg in patients with albuminuria 2
• Use angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) as first-line therapy, especially in patients with albuminuria 3, 5
• Consider combination therapy with dihydropyridine calcium channel blockers and/or diuretics when needed to achieve blood pressure targets 1
• Monitor kidney function and potassium levels when using RAAS blockers 5

Glycemic Control in Diabetic CKD

• Optimize glycemic control from diagnosis to slow CKD progression 3
• Prioritize SGLT2 inhibitors in patients with type 2 diabetes and CKD due to their renoprotective effects 3, 2
• Consider GLP-1 receptor agonists for patients with high cardiovascular risk 3

Lipid Management

• For patients with CKD stage 4, target LDL-C ≤55 mg/dl (1.4 mmol/l) with at least 50% reduction from baseline 3
• For patients with CKD stage 3, target LDL-C ≤70 mg/dl (1.8 mmol/l) with at least 50% reduction from baseline 3
• Use statins as first-line therapy, with or without ezetimibe 3
• Consider PCSK9 inhibitors in combination with maximally tolerated statin doses for patients not reaching targets 3

Management of CKD Complications

• Monitor and treat laboratory abnormalities associated with CKD, including anemia, mineral and bone disorders, potassium disorders, and acidosis 1
• Address cardiovascular risk factors aggressively as CKD is considered a marker of high or very high cardiovascular risk 3
• Evaluate for and manage other complications including gout and infections 1

Emerging Therapies

• Consider finerenone (non-steroidal mineralocorticoid receptor antagonist) for appropriate patients to reduce risk of CKD progression 2
• Pentoxifylline may have a role in managing CKD by targeting inflammation 2
• Endothelin receptor antagonists (e.g., atrasentan) show promise in reducing renal events in diabetic CKD 2

Monitoring Disease Progression

• For eGFR monitoring, changes of >30% on subsequent testing exceed expected variability and warrant evaluation 1
• For albuminuria monitoring, doubling of the ACR on a subsequent test exceeds laboratory variability and warrants evaluation 1
• Use disease-specific prediction equations for patients with IgA nephropathy or autosomal dominant polycystic kidney disease 1

Special Considerations

• Pediatric patients should be encouraged to undertake physical activity for ≥60 minutes daily and achieve a healthy weight 1
• Risk prediction equations developed for CKD G3-G5 may not be valid for those with CKD G1-G2 1
• For patients approaching kidney failure, timely preparation for kidney replacement therapy is essential, including vascular access planning and transplant referral 1