What are the management steps for Chronic Kidney Disease (CKD) according to the Philippines Clinical Practice Guidelines (CPG)?

Management of Chronic Kidney Disease Based on Philippine CPG Guidelines

The management of chronic kidney disease (CKD) 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
• Establish the cause of CKD using clinical context, personal and family history, social and environmental factors, medications, physical examination, laboratory measures, imaging, and genetic and pathologic diagnosis 2
• Test people at risk for CKD using both urine albumin measurement and assessment of glomerular filtration rate (GFR) 2
• Repeat tests to confirm presence of CKD following incidental detection of elevated urinary albumin-to-creatinine ratio (ACR), hematuria, or low estimated GFR (eGFR) 2

Blood Pressure Management

• Target blood pressure <140/90 mmHg in CKD patients without albuminuria 1
• Aim for a lower target of <130/80 mmHg in patients with albuminuria ≥30 mg/24h 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

Cardiovascular Risk Reduction

• Prescribe statins or statin/ezetimibe combination for adults ≥50 years with eGFR <60 ml/min/1.73 m² (CKD G3a-G5) 1, 3
• Choose statin regimens that maximize absolute reduction in LDL cholesterol to achieve largest treatment benefits 3
• For adults aged 18-49 years with CKD, consider statin therapy for those with coronary disease, diabetes mellitus, prior ischemic stroke, or estimated 10-year incidence of coronary death or nonfatal MI >10% 3
• Consider PCSK-9 inhibitors for CKD patients who have an indication for their use 3, 4

Lifestyle Modifications

• Recommend moderate-intensity physical activity for at least 150 minutes per week, adjusted to cardiovascular and physical tolerance 2, 1
• Advise patients to avoid sedentary behavior 2
• Encourage weight loss for patients with obesity and CKD 2
• Promote smoking cessation 2, 1
• For people at higher risk of falls, provide advice on the intensity of physical activity (low, moderate, or vigorous) and the type of exercises (aerobic vs. resistance, or both) 2

Dietary Management

• Advise adoption of healthy, diverse diets with higher consumption of plant-based foods and lower consumption of ultra-processed foods 2, 1
• Maintain protein intake at 0.8 g/kg body weight/day in adults with CKD G3-G5 2, 1
• Avoid high protein intake (>1.3 g/kg body weight/day) in adults with CKD at risk of progression 2, 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 2, 1
• Do not prescribe low- or very low-protein diets in metabolically unstable people with CKD 2
• Use renal dietitians or accredited nutrition providers to educate people with CKD about dietary adaptations regarding sodium, phosphorus, potassium, and protein intake 2

Management of Metabolic Complications

• Treat symptomatic hyperuricemia (gout) with urate-lowering therapy, preferring xanthine oxidase inhibitors over uricosuric agents 1
• Do not prescribe urate-lowering therapy for asymptomatic hyperuricemia to delay CKD progression 1
• Provide pharmacological treatment with or without dietary intervention to prevent acidosis (serum bicarbonate <18 mmol/L) 1
• Monitor treatment to ensure serum bicarbonate doesn't exceed normal limits and doesn't negatively impact blood pressure, serum potassium, or fluid balance 1

Medication Management

• Consider GFR when dosing medications cleared by the kidneys 2
• For most people and clinical settings, validated eGFR equations using serum creatinine are appropriate for drug dosing 2
• Where more accuracy is required for drug-related decision-making, use equations that combine both creatinine and cystatin C, or measured GFR 2
• Perform thorough medication review periodically and at transitions of care to assess adherence, continued indication, and potential drug interactions 2
• Consider planned discontinuation of medications (such as metformin, ACEi, ARBs, and SGLT2i) in the 48–72 hours prior to elective surgery or during acute management of adverse effects 2
• If medications are discontinued during an acute illness, communicate a clear plan of when to restart the discontinued medications 2
• Review and limit the use of over-the-counter medicines and dietary or herbal remedies that may be harmful for people with CKD 2

Referral to Specialist Kidney Care

• Refer adults with CKD to specialist kidney care services when they have:
  • ACR ≥30 mg/g (3 mg/mmol) or PCR ≥200 mg/g (20 mg/mmol)
  • Persistent hematuria
  • Any sustained decrease in eGFR
  • Hypertension that is difficult to control
  • Known or suspected genetic causes of CKD 2

Special Populations

• For children with CKD, encourage physical activity aiming for WHO-advised levels (≥60 minutes daily) and achievement of healthy weight 2, 1
• Do not restrict protein intake in children with CKD due to risk of growth impairment 2, 1
• When prescribing medications to people with CKD who are of child-bearing potential, always review teratogenicity potential and provide regular reproductive and contraceptive counseling 2

Common Pitfalls and Caveats

• Do not assume chronicity based upon a single abnormal level for eGFR and ACR, as the finding could be the result of a recent acute kidney injury (AKI) event or acute kidney disease (AKD) 2
• For patients on dialysis, the evidence for statin initiation is less clear, but current guidelines suggest not initiating statins in dialysis patients but continuing them if already prescribed 3
• Failure to restart medications after discontinuation during acute illness or procedures may lead to unintentional harm 2
• Recognize that in low- and middle-income countries, there is a large gap between CKD burden and provision of adequate healthcare, making early intervention to slow CKD progression a priority 2