What are the management guidelines for patients with Chronic Kidney Disease (CKD)?

Comprehensive Management Guidelines for Chronic Kidney Disease (CKD)

The management of chronic kidney disease requires a comprehensive treatment strategy targeting blood pressure control, cardiovascular risk reduction, lifestyle modifications, and monitoring for complications to reduce the risk of disease progression and associated morbidity and mortality. 1

Risk Assessment and Monitoring

• Use validated risk prediction tools to guide management decisions, with a 2-year kidney failure risk threshold of >10% determining timing for multidisciplinary care and >40% for kidney replacement therapy preparation 1
• For cardiovascular risk prediction, use externally validated models that incorporate eGFR and albuminuria to guide preventive therapies 1
• Monitor for complications of CKD including hyperkalemia, metabolic acidosis, hyperphosphatemia, vitamin D deficiency, secondary hyperparathyroidism, and anemia 2

Blood Pressure Management

• In CKD patients without albuminuria, target blood pressure should be <140/90 mmHg 1
• In patients with albuminuria ≥30 mg/24h, aim for a lower target of <130/80 mmHg 1
• Use angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARBs) as first-line therapy, especially in patients with albuminuria 1
• Titrate ACEi or ARBs to the highest approved dose that is tolerated to maximize kidney protection 1
• Multiple pharmacological agents are often needed to achieve BP targets 1

Cardiovascular Risk Reduction

• Prescribe statins or statin/ezetimib combination for adults ≥50 years with eGFR <60 ml/min/1.73 m² (CKD G3a-G5) 3
• For adults 18-49 years with CKD, consider statin therapy when additional risk factors are present (coronary heart disease, diabetes, prior ischemic stroke, or 10-year cardiovascular risk >10%) 3
• Choose statin-based therapies that maximize absolute reduction of LDL-cholesterol 3
• Recommend a plant-based "Mediterranean" diet in addition to lipid-lowering therapy 3

Lifestyle Modifications

• Recommend moderate-intensity physical activity for at least 150 minutes per week, adjusted to cardiovascular and physical tolerance 1
• Advise patients to avoid sedentary behavior 1
• Encourage weight loss for patients with obesity and CKD 1
• Promote smoking cessation 1, 4
• Advise adoption of healthy, diverse diets with higher consumption of plant-based foods and lower consumption of ultra-processed foods 1

Dietary Management

• Maintain protein intake at 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
• For patients at high risk of kidney failure who are willing and able, consider a very low-protein diet (0.3-0.4 g/kg body weight/day) with essential amino acid or ketoacid analog supplementation under close supervision 1
• Limit foods with high potassium content in patients with history of hyperkalemia 3
• Restrict dietary sodium intake 5

Management of Metabolic Complications

Hyperuricemia

• Treat symptomatic hyperuricemia (gout) with urate-lowering therapy, preferring xanthine oxidase inhibitors over uricosuric agents 3
• Do not prescribe urate-lowering therapy for asymptomatic hyperuricemia to delay CKD progression 3
• Recommend non-pharmacological measures for gout prevention (limiting alcohol, meat, and high-fructose corn syrup) 3

Metabolic Acidosis

• Provide pharmacological treatment with or without dietary intervention to prevent acidosis (serum bicarbonate <18 mmol/L) 3
• Monitor treatment to ensure serum bicarbonate doesn't exceed normal limits and doesn't negatively impact blood pressure, serum potassium, or fluid balance 3

Medication Management

• Adjust medication dosages according to kidney function 3, 2
• Avoid nephrotoxic medications, particularly non-steroidal anti-inflammatory drugs 2, 6
• For patients with atrial fibrillation, prefer non-vitamin K antagonist oral anticoagulants (NOACs) over vitamin K antagonists, with appropriate dose adjustments based on GFR 3

Referral to Nephrology

• Refer patients with eGFR <30 mL/min/1.73 m², severe albuminuria, or acute kidney injury to nephrology specialists 6
• Establish protocols for joint follow-up between primary care and nephrology in each health area 7
• Consider multidisciplinary ACKD (Advanced Chronic Kidney Disease) units including nephrologist, nephrology nurse, dietitian, and social worker for integrated management of patients with advanced CKD 7

Special Populations

• For children with CKD, encourage physical activity aiming for WHO-advised levels (≥60 minutes daily) and achievement of healthy weight 1
• Do not restrict protein intake in children with CKD due to risk of growth impairment 1