What are the first line management options for patients with Chronic Kidney Disease (CKD)?

First-Line Management Options for Chronic Kidney Disease (CKD)

The first-line management of chronic kidney disease should follow a comprehensive treatment strategy including SGLT2 inhibitors, RAS inhibitors (for hypertension), statins, and lifestyle modifications to reduce risks of CKD progression and its associated complications. 1

Holistic Approach to CKD Management

Regular Risk Factor Assessment

• Perform regular risk factor reassessment every 3-6 months to monitor disease progression and treatment efficacy 1
• Use validated risk equations to estimate the absolute risk of kidney failure for individual patients to guide treatment decisions and referral timing 1

First-Line Pharmacological Therapy

• SGLT2 inhibitors should be initiated when eGFR is ≥20 mL/min/1.73 m² and continued until dialysis or transplantation 1
• RAS inhibitors (ACE inhibitors or ARBs) at maximum tolerated dose should be first-line therapy for blood pressure control, especially when albuminuria is present 1
• Statins (moderate or high-intensity) should be prescribed for cardiovascular risk reduction 1, 2
• Blood pressure target should be SBP <120 mmHg if tolerated; <130/80 mmHg in patients with albuminuria and <140/90 mmHg in those without albuminuria 1, 3

Lifestyle Modifications

Physical Activity

• Recommend moderate-intensity physical activity for a cumulative duration of at least 150 minutes per week, adjusted to cardiovascular and physical tolerance 1, 4
• Physical activity should be compatible with the patient's level of frailty and cardiovascular health 1

Dietary Recommendations

• Encourage plant-based diets with protein intake adjusted according to individual needs and status 1
• Avoid high-protein intake but do not restrict protein in patients who are cachexic, sarcopenic, or undernourished 1
• Implement sodium restriction to aid in blood pressure management 1, 5
• Consider referral to renal dietitians or accredited nutrition providers for personalized dietary guidance 1

Other Lifestyle Factors

• Strongly advise complete cessation of tobacco products 1, 3
• Recommend weight management to achieve optimal body mass index 1
• Avoid binge alcohol drinking as it increases risk of CKD progression 3, 4

Management of CKD Complications

Targeted Therapies for Specific Complications

• For patients with diabetes, manage hyperglycemia according to KDIGO Diabetes Guidelines, including use of GLP-1 receptor agonists where indicated 1
• Consider nonsteroidal mineralocorticoid receptor antagonists (ns-MRA) in people with diabetes and persistent albuminuria 1
• Add dihydropyridine calcium channel blockers and/or diuretics if needed to achieve individualized BP targets 1
• Prescribe antiplatelet agents for patients with clinical atherosclerotic cardiovascular disease 1
• Manage anemia, CKD-mineral and bone disorder, acidosis, and potassium abnormalities as indicated 1, 6

Lipid Management

• For stage 3 CKD, aim for LDL-C ≤70 mg/dL (1.8 mmol/L) with at least 50% reduction from baseline 2
• For stage 4 CKD, aim for LDL-C ≤55 mg/dL (1.4 mmol/L) with at least 50% reduction from baseline 2
• Consider adding ezetimibe or PCSK9 inhibitors based on ASCVD risk and lipid levels 1, 2

Common Pitfalls and Caveats

• Avoid restricting protein in patients who are undernourished, cachexic, or sarcopenic as this can worsen nutritional status 1
• Do not increase medication doses too frequently; avoid increasing doses more than once every 4 weeks 6
• Be cautious with very low-protein diets; they require close supervision 1
• Recognize that patients with CKD are at higher risk for medication side effects and require dose adjustments for many medications 7, 8
• Avoid nephrotoxic medications, particularly nonsteroidal anti-inflammatory drugs (NSAIDs) 8
• Monitor for and manage complications early, including hyperkalemia, metabolic acidosis, hyperphosphatemia, vitamin D deficiency, secondary hyperparathyroidism, and anemia 8