What are the management strategies for patients with kidney disease, including treatment of hypertension and diabetes?

Management Strategies for Patients with Kidney Disease

The management of patients with chronic kidney disease (CKD) should include a comprehensive strategy targeting blood pressure control (<130/80 mmHg), glycemic management, renin-angiotensin system inhibition, and lifestyle modifications to reduce the risk of kidney disease progression and cardiovascular disease. 1

Blood Pressure Management

• Blood pressure should be maintained below 130/80 mmHg for all patients with diabetes and CKD to reduce cardiovascular mortality and slow CKD progression 1
• Renin-angiotensin system inhibitors (RASi) are the cornerstone of treatment:
  • ACE inhibitors or ARBs should be initiated in patients with diabetes, hypertension, and albuminuria, and titrated to the highest approved dose that is tolerated 1
  • For patients with severely increased albuminuria (≥300 mg/g creatinine) without diabetes, RASi therapy is strongly recommended 1
  • For patients with moderately increased albuminuria (30-299 mg/g creatinine) without diabetes, RASi therapy should be considered 1
• Monitor serum creatinine and potassium within 2-4 weeks after starting or changing the dose of ACEi or ARB 1
• Continue ACEi or ARB therapy unless serum creatinine rises by more than 30% within 4 weeks following initiation or dose increase 1
• Avoid any combination of ACEi, ARB, and direct renin inhibitor therapy 1
• Dihydropyridine calcium channel blockers can be used as alternative first-line agents in kidney transplant recipients 1

Glycemic Control in Diabetic Kidney Disease

• Intensive glycemic control delays the onset and progression of albuminuria and reduces eGFR decline in both type 1 and type 2 diabetes 1
• For patients with type 2 diabetes and CKD, consider special medication selection based on eGFR limitations 1
• Metformin guidelines for CKD patients:
  • Contraindicated when eGFR <30 mL/min/1.73 m² 1
  • Should not be initiated when eGFR <45 mL/min/1.73 m² 1
  • Reassess benefits and risks when eGFR falls below 45 mL/min/1.73 m² 1
  • Temporarily discontinue before iodinated contrast procedures in patients with eGFR 30-60 mL/min/1.73 m² 1
• SGLT2 inhibitors are recommended for patients with type 2 diabetes and CKD when eGFR is ≥30 mL/min/1.73 m² due to their renoprotective effects 1

Nutrition and Lifestyle Management

• Dietary protein intake should be 0.8 g/kg body weight per day for non-dialysis CKD patients 1
• Higher protein intake (>20% of daily calories or >1.3 g/kg/day) should be avoided as it increases albuminuria and accelerates kidney function loss 1
• Restrict dietary sodium to <2,300 mg/day to help control blood pressure and reduce cardiovascular risk 1
• Individualize dietary potassium intake based on serum potassium levels, especially in patients with reduced eGFR 1
• Encourage moderate-intensity physical activity for at least 150 minutes per week 1
• Smoking cessation is essential as it reduces albuminuria 1

Surveillance and Monitoring

• Monitor both albuminuria and eGFR annually to enable timely diagnosis of CKD, track progression, detect superimposed kidney diseases, and assess risk of complications 1
• Monitor serum potassium in patients treated with diuretics, ACEi, ARBs, or mineralocorticoid receptor antagonists, especially those with eGFR <60 mL/min/1.73 m² 1
• Screen for CKD complications when eGFR falls below 60 mL/min/1.73 m² (stage G3 CKD or greater) 1:
  • Volume overload
  • Electrolyte abnormalities
  • Metabolic acidosis
  • Anemia
  • Metabolic bone disease

Special Considerations

• For patients with diabetic nephropathy, losartan is indicated for treatment when there is elevated serum creatinine and proteinuria (urinary albumin to creatinine ratio ≥300 mg/g) in patients with type 2 diabetes and hypertension 2
• Losartan reduces the rate of progression of nephropathy as measured by the occurrence of doubling of serum creatinine or end-stage renal disease 2
• In patients with prevalent CKD and substantial comorbidity, less intensive A1C targets may be appropriate due to increased risk of hypoglycemia 1
• Mineralocorticoid receptor antagonists can be effective for management of refractory hypertension but may cause hyperkalemia or reversible decline in kidney function, particularly in patients with low eGFR 1

Common Pitfalls and Caveats

• Hyperkalemia with ACEi/ARB use should be managed with measures to reduce potassium levels rather than immediately decreasing the dose or stopping the medication 1
• Avoid nephrotoxic medications (e.g., NSAIDs) in patients with reduced eGFR 1
• There is no evidence that RASi prevent the development of diabetic kidney disease in the absence of hypertension or albuminuria 1
• The lag time for effects of intensive glucose control on eGFR outcomes is at least 2 years in type 2 diabetes and over 10 years in type 1 diabetes 1
• Black patients may have a smaller average response to RASi monotherapy than non-Black patients, but this difference disappears with combination therapy 3