Management of Chronic Kidney Disease (CKD)
The recommended treatment for Chronic Kidney Disease (CKD) should focus on blood pressure control with a target of <130/80 mmHg using ACE inhibitors or ARBs as first-line therapy, along with cardiovascular risk reduction through statins, lifestyle modifications, and management of metabolic complications. 1, 2, 3
Blood Pressure Management
- Target blood pressure should be <130/80 mmHg for all patients with CKD to reduce cardiovascular mortality and slow CKD progression 1, 3
- First-line pharmacological therapy should include an angiotensin-converting enzyme (ACE) inhibitor or angiotensin II receptor blocker (ARB) if ACE inhibitors are not tolerated 1, 2, 3
- For black patients with CKD, initial therapy should be a thiazide-type diuretic or calcium channel blocker, with an ACEI or ARB added if the patient has proteinuria 1
- Blood pressure monitoring should preferably use 24-hour ambulatory devices for accurate assessment 2
- Multiple antihypertensive medications are often required to achieve target blood pressure in CKD patients 3
Cardiovascular Risk Reduction
- For adults ≥50 years with eGFR <60 ml/min/1.73 m² (CKD G3a-G5), statin or statin/ezetimibe combination therapy is strongly recommended (Grade 1A) 1
- For adults ≥50 years with CKD and eGFR ≥60 ml/min/1.73 m² (CKD G1-G2), statin therapy is recommended (Grade 1B) 1
- For adults aged 18-49 years with CKD, statin therapy is suggested if they have coronary disease, diabetes mellitus, prior ischemic stroke, or estimated 10-year cardiovascular risk >10% 1, 4
- Low-dose aspirin is recommended for secondary prevention in patients with established cardiovascular disease 1
- Consider PCSK9 inhibitors for people with CKD who have an indication for their use 1
Dietary and Lifestyle Modifications
- A plant-based "Mediterranean-style" diet is recommended in addition to pharmacological therapy 1, 2
- Sodium restriction is recommended to help control blood pressure 2, 5
- Limit alcohol, meats, and high-fructose corn syrup intake 1, 4
- Regular physical exercise and weight reduction for overweight or obese patients are recommended 5
Management of Diabetes in CKD
- For patients with diabetes and CKD, target A1C levels may need to be less intensive due to increased risk of hypoglycemia 1
- Metformin is contraindicated in patients with an eGFR <30 ml/min/1.73 m² 1
- The benefits and risks of continuing metformin should be reassessed when eGFR falls to <45 ml/min/1.73 m² 1
- SGLT2 inhibitors should be considered for patients with type 2 diabetes and CKD due to their renoprotective effects 1, 5
Management of Metabolic Complications
- For metabolic acidosis, pharmacological treatment with or without dietary intervention is recommended to prevent acidosis (serum bicarbonate <18 mmol/l) 4
- For hyperkalemia, an individualized approach including dietary and pharmacological interventions is recommended 4
- For hyperuricemia, treatment is recommended for symptomatic hyperuricemia (gout), but not for asymptomatic hyperuricemia to delay CKD progression 1, 4
Special Considerations
- For patients with atrial fibrillation, non-vitamin K antagonist oral anticoagulants (NOACs) are preferred over warfarin, with appropriate dose adjustments based on kidney function 1, 4
- In stable stress-test confirmed ischemic heart disease, an initial conservative approach using intensive medical therapy is an appropriate alternative to an initial invasive strategy 1
- Initial management with an invasive strategy may still be preferable for people with CKD with acute or unstable coronary disease, unacceptable levels of angina, left ventricular systolic dysfunction attributable to ischemia, or left main disease 1