What are the key concepts, management, and treatment options for Chronic Kidney Disease (CKD), including dialysis?

Comprehensive Management of Chronic Kidney Disease (CKD)

Chronic kidney disease requires a comprehensive treatment strategy focusing on slowing progression, managing complications, and optimizing quality of life through targeted interventions based on CKD stage, albuminuria level, and underlying cause. 1

Definition and Classification

• CKD is defined as abnormalities in kidney structure or function present for more than 3 months with health implications 1
• Classification uses the CGA system: Cause, Glomerular filtration rate (GFR) category (G1-G5), and Albuminuria level (A1-A3) 1
• GFR categories: G1 (≥90), G2 (60-89), G3a (45-59), G3b (30-44), G4 (15-29), G5 (<15 ml/min/1.73m²) 1
• Albuminuria categories: A1 (<30 mg/g), A2 (30-300 mg/g), A3 (>300 mg/g) 1
• Diagnosis requires either GFR <60 ml/min/1.73m² or evidence of kidney damage (albuminuria, abnormal urinalysis, imaging, or biopsy) for >3 months 1, 2

Screening and Early Detection

• Screen high-risk populations: diabetes, hypertension, cardiovascular disease, age >60, family history of kidney disease, previous acute kidney injury, or preeclampsia 2, 3
• Screening tests include serum creatinine to calculate eGFR using the CKD-EPI equation without race variable, and urine albumin-to-creatinine ratio 2, 4
• Early detection can prevent progression, reduce cardiovascular risk, and decrease mortality 3
• Consider serum cystatin C to confirm eGFR in patients with CKD, especially when false-positive decreased eGFR is suspected 2, 5

Risk Assessment and Referral

• Use validated risk prediction tools to estimate 2-year kidney failure risk 1
• Consider nephrology referral for: eGFR <30 ml/min/1.73m², persistent urine albumin/creatinine ratio >300 mg/g, or rapid loss of kidney function 5
• A 2-year kidney failure risk >10% indicates need for multidisciplinary care 1
• A 2-year kidney failure risk >40% indicates need for kidney replacement therapy preparation 1

Core Management Strategies

Blood Pressure Control

• Maintain blood pressure <140/90 mmHg, with systolic target of ≤120 mmHg for patients who tolerate therapy 2
• Use angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARBs) as first-line therapy, especially in patients with albuminuria 1, 2
• Titrate ACEi or ARBs to the highest approved dose that is tolerated 1

Glycemic Control in Diabetic CKD

• First-line treatment for type 2 diabetes with CKD should include metformin and a sodium-glucose cotransporter-2 inhibitor (SGLT2i) when eGFR ≥30 ml/min/1.73m² 1
• Metformin is recommended for patients with T2D, CKD, and eGFR ≥30 ml/min/1.73m² 1
• Adjust metformin dose when eGFR <45 ml/min/1.73m² and halve the dose at eGFR 30-44 ml/min/1.73m² 1
• For additional glycemic control, glucagon-like peptide-1 receptor agonists (GLP-1 RA) are generally preferred 1

Cardiovascular Risk Reduction

• Statin therapy is recommended for adults ≥50 years with eGFR <60 ml/min/1.73m² (statin or statin/ezetimibe combination) 1
• Statin therapy is also recommended for adults ≥50 years with CKD and eGFR ≥60 ml/min/1.73m² 1
• For adults 18-49 years with CKD, consider statin therapy if they have coronary disease, diabetes, prior stroke, or 10-year cardiovascular risk >10% 1
• Low-dose aspirin is recommended for secondary prevention in CKD patients with established cardiovascular disease 1

Lifestyle Modifications

• Physical activity: Recommend moderate-intensity physical activity for at least 150 minutes per week, adjusted to cardiovascular and physical tolerance 1
• Diet: Advise healthy, diverse diets with emphasis on plant-based "Mediterranean-style" eating patterns 1
• Weight management: Encourage weight loss for patients with obesity and CKD, particularly with eGFR ≥30 ml/min/1.73m² 1
• Smoking cessation: All patients with CKD should be advised not to use tobacco products 1

Management of CKD Complications

Hyperkalemia

• Individualized approach for hyperkalemia including dietary and pharmacologic interventions 1
• Limit intake of foods rich in bioavailable potassium (e.g., processed foods) for CKD G3-G5 patients with history of hyperkalemia 1

Hyperuricemia

• Treat symptomatic hyperuricemia (gout) with uric acid-lowering therapy 1
• Prefer xanthine oxidase inhibitors over uricosuric agents 1
• For acute gout in CKD, use low-dose colchicine or intra-articular/oral glucocorticoids rather than NSAIDs 1
• Asymptomatic hyperuricemia does not require treatment to delay CKD progression 1

Anemia

• Evaluate iron status before and during treatment with erythropoiesis-stimulating agents (ESAs) 6
• For CKD patients on dialysis, initiate ESA treatment when hemoglobin is <10 g/dL 6
• For CKD patients not on dialysis, consider ESA only when hemoglobin is <10 g/dL and risk of transfusion is a concern 6
• Target hemoglobin should not exceed 11 g/dL due to increased risks of death, cardiovascular events, and stroke 6

Dialysis Considerations

When to Start Dialysis

• Consider dialysis when patients reach CKD stage 5 (eGFR <15 ml/min/1.73m²) 1
• Evaluate benefits, risks, and disadvantages of beginning kidney replacement therapy 1
• Clinical considerations and complications may prompt earlier initiation of therapy 1
• Conservative therapy without dialysis may be appropriate for some patients 1

Preparation for Kidney Replacement Therapy

• Patients with CKD stage 4 (eGFR <30 ml/min/1.73m²) should receive education about kidney failure treatment options 1
• Options include kidney transplantation, peritoneal dialysis, hemodialysis (home or in-center), and conservative management 1
• Educate patients' family members and caregivers about treatment choices 1
• Consider kidney replacement therapy preparation when 2-year kidney failure risk exceeds 40% 1

Dialysis Modalities

• Recognize that kidney dysfunction requiring dialysis (KDRD) is heterogeneous with varying levels of residual kidney function 7
• Consider personalized, physiological approaches to hemodialysis therapy based on endogenous kidney function and patient-reported symptoms 7
• Peritoneal dialysis is a viable home-based option for many patients 1

Common Pitfalls and Caveats

• Avoid using a single abnormal laboratory result to guide treatment decisions; focus on trends 1
• Be cautious to avoid hypercalcemia when treating secondary hyperparathyroidism 1
• Avoid NSAIDs in CKD patients, especially during acute gout flares 1
• Avoid intravenous iodinated contrast media in patients with advanced CKD 2
• Adjust medication dosages based on eGFR, particularly for metformin and other renally cleared drugs 1
• Don't delay nephrology referral for patients with eGFR <30 ml/min/1.73m² or rapidly declining kidney function 5