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

Comprehensive Management of Chronic Kidney Disease (CKD)

The management of chronic kidney disease requires a comprehensive strategy that addresses lifestyle modifications, blood pressure control, glycemic management, cardiovascular risk reduction, and treatment of CKD-specific complications to reduce morbidity, mortality, and improve quality of life. 1

Core Management Strategies

Lifestyle Modifications

• Recommend moderate-intensity physical activity for at least 150 minutes per week, adjusted to the patient's cardiovascular and physical tolerance 1
• Advise patients to avoid sedentary behavior and provide specific guidance on exercise intensity based on fall risk 1
• Encourage smoking cessation as tobacco use accelerates CKD progression 1, 2
• Target optimal body weight with weight loss recommendations for patients with obesity 1
• Recommend healthy, diverse diets with higher consumption of plant-based foods compared to animal-based foods and lower consumption of ultraprocessed foods 1
• Maintain protein intake at 0.8 g/kg body weight/day for adults with CKD G3-G5 and avoid high protein intake (>1.3 g/kg/day) in those at risk of progression 1
• Reduce sodium intake to <2 g per day to help control blood pressure and reduce proteinuria 1

Blood Pressure Management

• For patients with albuminuria ≥30 mg/24 hours, target blood pressure ≤130/80 mmHg 1
• For patients with urine albumin excretion <30 mg/24 hours, target blood pressure ≤140/90 mmHg 1
• Use angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) as first-line therapy for patients with albuminuria >300 mg/24 hours 1
• Add dihydropyridine calcium channel blockers and/or diuretics as needed to achieve blood pressure targets 1
• Consider steroidal mineralocorticoid receptor antagonists for resistant hypertension 1

Glycemic Control in Diabetic CKD

• Implement comprehensive diabetes management according to KDIGO guidelines 1
• Use metformin as first-line therapy when eGFR ≥30 ml/min/1.73m² 1
• Add SGLT2 inhibitors when eGFR ≥20 ml/min/1.73m² and continue until dialysis or transplantation 1
• Consider GLP-1 receptor agonists when SGLT2 inhibitors and metformin are insufficient to meet glycemic targets 1
• Target hemoglobin A1c level of approximately 7% 1

Cardiovascular Risk Reduction

• Prescribe statins for all adults aged ≥50 years with CKD (regardless of GFR category) 1
• For adults aged 18-49 years with CKD, recommend statin therapy if they have coronary disease, diabetes, prior stroke, or 10-year coronary event risk >10% 1
• Add ezetimibe based on ASCVD risk and lipid levels 1
• Consider antiplatelet therapy for patients with established cardiovascular disease 1

Management of CKD-Specific Complications

Metabolic Acidosis

• Consider pharmacological treatment with or without dietary intervention when serum bicarbonate <18 mmol/l 1
• Monitor treatment to ensure bicarbonate doesn't exceed the upper limit of normal or adversely affect blood pressure, potassium, or fluid status 1

Hyperkalemia

• Implement an individualized approach for patients with CKD G3-G5 and hyperkalemia, including dietary and pharmacologic interventions 1
• Limit intake of foods rich in bioavailable potassium (e.g., processed foods) for patients with history of hyperkalemia 1
• Be aware of factors affecting potassium measurement including diurnal variation, sample type, and medication effects 1

Hyperuricemia

• Offer uric acid-lowering therapy for patients with symptomatic hyperuricemia 1
• Consider initiating uric acid-lowering therapy after the first episode of gout, particularly with serum uric acid >9 mg/dl 1
• Use xanthine oxidase inhibitors rather than uricosuric agents 1
• For acute gout, prefer low-dose colchicine or glucocorticoids over NSAIDs 1
• Do not use uric acid-lowering agents for asymptomatic hyperuricemia to delay CKD progression 1

Anemia and CKD-MBD

• Manage anemia, CKD-mineral and bone disorder (CKD-MBD), and other metabolic abnormalities according to established guidelines 1

Monitoring and Risk Assessment

• Assess risk factors regularly (every 3-6 months) 1
• Monitor for CKD progression using both blood and urine tests, with frequency guided by individual risk 1
• Consider all people with CKD at increased risk for acute kidney injury (AKI) 1
• Use validated risk equations to estimate absolute risk of kidney failure for individual patients 1
• Recognize that small fluctuations in GFR are common and do not necessarily indicate progression 1

Symptom Management

• Regularly screen for symptoms using validated tools 1
• Address pain using a stepwise approach, starting with non-pharmacological interventions and advancing to pharmacological therapy as needed 1
• Screen for and treat depression, which affects approximately 26.5% of patients with CKD stages 1-4 1

Referral to Specialists

• Refer patients to renal dietitians or accredited nutrition providers for dietary education tailored to individual needs 1
• Consider referral to other specialists (psychologists, pharmacists, physical therapy) as indicated 1
• Refer patients at high risk of progression to end-stage renal disease to a nephrologist 3

Special Considerations

• For patients at higher risk of falls, provide specific advice on exercise intensity and type 1
• Adapt recommendations for physical activity considering age, ethnic background, comorbidities, and resource access 1
• For children with CKD, encourage physical activity aiming for 60 minutes daily and achievement of healthy weight 1

By implementing this comprehensive management approach, healthcare providers can effectively reduce the risk of CKD progression, cardiovascular complications, and mortality while improving quality of life for patients with CKD 4, 5.