What are the initial recommendations for Chronic Kidney Disease (CKD) management?

Initial Management of Chronic Kidney Disease (CKD)

People with CKD should be treated with a comprehensive treatment strategy targeting lifestyle modifications, blood pressure control, cardiovascular risk reduction, and monitoring for complications to reduce the risk of disease progression and associated morbidity and mortality. 1, 2

Lifestyle Modifications

• Advise patients to undertake moderate-intensity physical activity for at least 150 minutes per week, adjusted to their cardiovascular and physical tolerance 1, 2
• Encourage patients to avoid sedentary behavior and maintain an active lifestyle 1, 2
• Recommend weight loss for patients with obesity and CKD 1, 3
• Promote smoking cessation and abstinence from tobacco products 1, 2
• 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 1, 4
• Maintain protein intake at 0.8 g/kg body weight/day in adults with CKD G3-G5 1, 2
• Avoid high protein intake (>1.3 g/kg body weight/day) in adults with CKD at risk of progression 1, 2
• Limit sodium intake to <2 g per day (or <5 g of sodium chloride per day) 4, 3

Blood Pressure Management

• Target blood pressure <140/90 mmHg in CKD patients without albuminuria 2, 3
• Aim for a lower target of <130/80 mmHg in patients with albuminuria ≥30 mg/24h 2, 3
• Use angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARBs) as first-line therapy, especially in patients with albuminuria 2, 3
• Consider less intensive BP-lowering therapy in people with frailty, high risk of falls, limited life expectancy, or symptomatic postural hypotension 4, 5

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, 2
• Prescribe statins for adults ≥50 years with CKD and eGFR ≥60 ml/min/1.73 m² (CKD G1-G2) 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% 1
• Choose statin regimens that maximize absolute reduction in LDL cholesterol to achieve largest treatment benefits 1, 2
• Consider PCSK-9 inhibitors for people with CKD who have an indication for their use 1, 4
• Recommend oral low-dose aspirin for secondary prevention in people with CKD and established ischemic cardiovascular disease 1, 4

Risk Assessment and Monitoring

• Use validated risk prediction tools to guide management decisions 2, 4
• Test people at risk for CKD using both urine albumin measurement and assessment of glomerular filtration rate (GFR) 2, 6
• 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, 5
• Monitor for complications of CKD such as hyperkalemia, metabolic acidosis, hyperphosphatemia, vitamin D deficiency, secondary hyperparathyroidism, and anemia 5, 4

Medication Management

• Consider GFR when dosing medications cleared by the kidneys 2, 4
• For most clinical settings, validated eGFR equations using serum creatinine are appropriate for drug dosing 2, 4
• Perform thorough medication review periodically and at transitions of care to assess adherence, continued indication, and potential drug interactions 2, 4
• For patients with diabetes and CKD, consider SGLT2 inhibitors as first-line agents along with metformin 7, 4

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, 4
• Refer adults with CKD to specialist kidney care services when they have persistent hematuria 2, 4
• Refer adults with CKD to specialist kidney care services when they have any sustained decrease in eGFR 2, 4
• Consider referral when patients have a 2-year kidney failure risk threshold of >10% 2, 4

Special Considerations

• For children with CKD, encourage physical activity aiming for WHO-advised levels (≥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 1, 2
• In older adults with frailty and sarcopenia, consider higher protein and calorie dietary targets 1, 8
• For patients with atrial fibrillation and CKD G1-G4, use non-vitamin K antagonist oral anticoagulants (NOACs) in preference to vitamin K antagonists 1, 4