What are the guidelines for managing Chronic Kidney Disease (CKD)?

Guidelines for Managing Chronic Kidney Disease (CKD)

The management of chronic kidney disease 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 2, 1
• Establish the cause of CKD using clinical context, personal and family history, 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 systolic blood pressure of <120 mm Hg when tolerated, using standardized office BP measurement 3
• Consider less intensive BP-lowering therapy in people with frailty, high risk of falls and fractures, limited life expectancy, or symptomatic postural hypotension 3
• In children with CKD, aim for 24-hour mean arterial pressure by ambulatory blood pressure monitoring to be ≤50th percentile for age, sex, and height 3
• Monitor BP once a year with ambulatory blood pressure monitoring and every 3–6 months with standardized office BP in children with CKD 3

Lifestyle Modifications

• Advise people with CKD to undertake moderate-intensity physical activity for at least 150 minutes per week, adjusted to their cardiovascular and physical tolerance 3
• Encourage patients to avoid sedentary behavior 3
• Consider advising people with obesity and CKD to lose weight 3
• Encourage children with CKD to undertake physical activity aiming for ≥60 minutes daily and to achieve a healthy weight 3
• Promote smoking cessation and abstinence from tobacco products 2

Dietary Management

• Advise adoption of healthy, diverse diets with higher consumption of plant-based foods compared to animal-based foods and lower consumption of ultra-processed foods 3
• Maintain protein intake at 0.8 g/kg body weight/day in adults with CKD G3–G5 3
• Avoid high protein intake (>1.3 g/kg body weight/day) in adults with CKD at risk of progression 3
• In motivated adults with CKD at risk of kidney failure, consider prescribing a very low-protein diet (0.3–0.4 g/kg body weight/day) supplemented with essential amino acids or ketoacid analogs under close supervision 3
• Do not prescribe low- or very low-protein diets in metabolically unstable people with CKD 3
• Do not restrict protein intake in children with CKD due to risk of growth impairment 3
• Consider higher protein and calorie dietary targets in older adults with frailty and sarcopenia 3
• Limit sodium intake to <2 g per day (or <5 g of sodium chloride per day) 3
• Dietary sodium restriction is usually not appropriate for patients with sodium-wasting nephropathy 3

Cardiovascular Risk Reduction

• Prescribe statins or statin/ezetimibe combination for adults ≥50 years with eGFR <60 ml/min/1.73 m² (CKD G3a-G5) 2, 1
• 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% 2, 1
• Choose statin regimens that maximize absolute reduction in LDL cholesterol 3
• Consider prescribing PCSK-9 inhibitors for people with CKD who have an indication for their use 3
• Consider a plant-based "Mediterranean-style" diet in addition to lipid-modifying therapy 3
• Recommend oral low-dose aspirin for secondary prevention in people with CKD and established ischemic cardiovascular disease 3
• Consider other antiplatelet therapy (e.g., P2Y12 inhibitors) when there is aspirin intolerance 3

Management of Atrial Fibrillation in CKD

• Use non-vitamin K antagonist oral anticoagulants (NOACs) in preference to vitamin K antagonists for thromboprophylaxis in atrial fibrillation in people with CKD G1–G4 3
• Adjust NOAC dose based on GFR, with caution needed at CKD G4–G5 3
• Consider duration of NOAC discontinuation before elective procedures based on procedural bleeding risk, NOAC prescribed, and level of GFR 3

Medication Management

• Consider GFR when dosing medications cleared by the kidneys 2
• For most clinical settings, validated eGFR equations using serum creatinine are appropriate for drug dosing 2
• Perform thorough medication review periodically and at transitions of care to assess adherence, continued indication, and potential drug interactions 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) 2
• Refer adults with CKD to specialist kidney care services when they have persistent hematuria 2
• Refer adults with CKD to specialist kidney care services when they have any sustained decrease in eGFR 2
• Patients with CKD stages 1-2 may be managed by primary care physicians, while individuals in stages 3-5 need supervision by nephrologists to assess progression to end-stage kidney disease and requirement for renal replacement therapy 4

Management of Metabolic Complications

• Treat symptomatic hyperuricemia (gout) with urate-lowering therapy, preferring xanthine oxidase inhibitors over uricosuric agents 5
• Do not prescribe urate-lowering therapy for asymptomatic hyperuricemia to delay CKD progression 5
• Provide pharmacological treatment with or without dietary intervention to prevent acidosis (serum bicarbonate <18 mmol/L) 5
• Monitor treatment to ensure serum bicarbonate doesn't exceed normal limits and doesn't negatively impact blood pressure, serum potassium, or fluid balance 5