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

Management of Chronic Kidney Disease (CKD)

The comprehensive management of chronic kidney disease requires targeting blood pressure control, cardiovascular risk reduction, lifestyle modifications, and monitoring for complications to reduce disease progression and associated morbidity and mortality. 1, 2

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 2
• Monitor for CKD progression using both blood and urine tests, with frequency guided by individual risk (every 3-6 months) 1, 2
• Consider all people with CKD at increased risk for acute kidney injury (AKI) 1
• Recognize that small fluctuations in GFR are common and do not necessarily indicate progression 1

Blood Pressure Management

• For CKD patients without albuminuria (<30 mg/24h), target blood pressure should be <140/90 mmHg 3
• For patients with albuminuria ≥30 mg/24h, aim for a lower target of <130/80 mmHg 3
• Use angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) as first-line therapy, especially in patients with albuminuria >300 mg/24h 3
• Add dihydropyridine calcium channel blockers and/or diuretics as needed to achieve blood pressure targets 1
• Inquire about postural dizziness and check for postural hypotension regularly when treating CKD patients with BP-lowering drugs 3

Lifestyle Modifications

• Recommend moderate-intensity physical activity for at least 150 minutes per week, adjusted to cardiovascular and physical tolerance 1, 4
• Advise patients to avoid sedentary behavior 1, 2
• Encourage weight loss for patients with obesity and CKD 1, 4
• Promote smoking cessation as tobacco use accelerates CKD progression 1, 4
• Recommend healthy, diverse diets with higher consumption of plant-based foods compared to animal-based foods and lower consumption of ultraprocessed foods 1, 2

Dietary Management

• Maintain protein intake at 0.8 g/kg body weight/day for adults with CKD G3-G5 1, 2
• Avoid high protein intake (>1.3 g/kg/day) in adults with CKD at risk of progression 1, 2
• Reduce sodium intake to <2 g per day to help control blood pressure and reduce proteinuria 1, 5
• Limit foods with high potassium content in patients with history of hyperkalemia 1, 2

Cardiovascular Risk Reduction

• Prescribe statins for all adults aged ≥50 years with CKD (regardless of GFR category) 1, 2
• Consider statin therapy for adults aged 18-49 years with CKD if they have coronary disease, diabetes, prior stroke, or 10-year coronary event risk >10% 1, 2
• Add ezetimibe based on ASCVD risk and lipid levels 1, 2
• Consider antiplatelet therapy for patients with established cardiovascular disease 1, 2

Management of Metabolic Complications

• Provide pharmacological treatment with or without dietary intervention to prevent acidosis (serum bicarbonate <18 mmol/L) 1, 2
• Monitor treatment to ensure serum bicarbonate doesn't exceed normal limits and doesn't negatively impact blood pressure, serum potassium, or fluid balance 1, 2
• Implement an individualized approach for patients with CKD G3-G5 and hyperkalemia, including dietary and pharmacologic interventions 1
• Be aware of factors affecting potassium measurement including diurnal variation, sample type, and medication effects 1

Glycemic Control in Diabetic CKD

• Implement comprehensive diabetes management according to guidelines 1
• Use metformin as first-line therapy when eGFR ≥30 ml/min/1.73m² 1
• Add SGLT2 inhibitors when eGFR ≥20 ml/min/1.73m² and continue until dialysis or transplantation 1, 6
• Consider GLP-1 receptor agonists when SGLT2 inhibitors and metformin are insufficient to meet glycemic targets 1, 6
• Target hemoglobin A1c level of approximately 7% 1

Anemia Management

• Evaluate iron status in all patients before and during treatment 7
• Administer supplemental iron therapy when serum ferritin is less than 100 mcg/L or when serum transferrin saturation is less than 20% 7
• For patients requiring erythropoiesis-stimulating agents (ESAs), use the lowest dose sufficient to reduce the need for RBC transfusions 7
• Initiate ESA treatment when hemoglobin level is less than 10 g/dL 7
• Monitor hemoglobin weekly until stable after initiating therapy or dose adjustment, then monthly 7

Medication Management

• Adjust medication dosages according to kidney function 2
• Implement deprescribing protocols to reduce pill burden and avoid potentially inappropriate medications 3
• For patients with atrial fibrillation, prefer non-vitamin K antagonist oral anticoagulants (NOACs) over vitamin K antagonists, with appropriate dose adjustments based on GFR 2
• Avoid nephrotoxic medications such as NSAIDs when possible 6, 8

Symptom Management

• Regularly screen for symptoms using validated tools 2
• Address pain using a stepwise approach, starting with non-pharmacological interventions and advancing to pharmacological therapy as needed 2
• Screen for and treat depression, which affects approximately 26.5% of patients with CKD stages 1-4 1

Special Considerations

• For children with CKD, encourage physical activity aiming for ≥60 minutes daily and achievement of healthy weight 1, 2
• Do not restrict protein intake in children with CKD due to risk of growth impairment 2
• Provide specific advice on exercise intensity and type for patients at higher risk of falls 1