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

Comprehensive Management of 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
• For cardiovascular risk prediction, use externally validated models that incorporate eGFR and albuminuria to guide preventive therapies 2
• Regular monitoring (every 3-6 months) of kidney function, albuminuria, and risk factors is essential for tracking disease progression 3, 1
• Consider all CKD patients at increased risk for acute kidney injury (AKI) and take preventive measures 2, 4

Blood Pressure Management

• Target blood pressure <140/90 mmHg in patients without albuminuria 2, 1
• Target lower blood pressure <130/80 mmHg in patients with albuminuria ≥30 mg/24h 2, 1
• Use angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) as first-line therapy, especially in patients with albuminuria >300 mg/24h 2, 3
• Titrate ACEIs or ARBs to the highest tolerated dose to maximize kidney protection 1, 5

Lifestyle Modifications

• Recommend moderate-intensity physical activity for at least 150 minutes per week, adjusted to cardiovascular and physical tolerance 2, 3
• Advise patients to avoid sedentary behavior 2, 3
• Encourage weight loss for patients with obesity and CKD 2, 6
• Promote smoking cessation as tobacco use accelerates CKD progression 3, 7
• For patients at higher risk of falls, provide specific advice on exercise intensity and type (low, moderate, or vigorous) and exercise type (aerobic vs. resistance) 2, 3

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 2, 3
• 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 motivated patients at high risk of kidney failure, 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
• Reduce sodium intake to <2 g per day to help control blood pressure and reduce proteinuria 2, 3
• Refer to renal dietitians or accredited nutrition providers for dietary education tailored to individual needs 2, 3

Glycemic Control in Diabetic CKD

• Implement comprehensive diabetes management according to current guidelines 2, 3
• Use metformin as first-line therapy when eGFR ≥30 ml/min/1.73m² 2, 3
• Add SGLT2 inhibitors when eGFR ≥20 ml/min/1.73m² and continue until dialysis or transplantation 2, 3
• Consider GLP-1 receptor agonists when SGLT2 inhibitors and metformin are insufficient to meet glycemic targets 2, 3
• Target hemoglobin A1c level of approximately 7% 2, 3

Cardiovascular Risk Reduction

• Prescribe statins for all adults aged ≥50 years with CKD (regardless of GFR category) 3, 1
• Recommend 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% 3, 1
• Add ezetimibe based on ASCVD risk and lipid levels 3, 1
• Consider antiplatelet therapy for patients with established cardiovascular disease 3, 1

Management of CKD-Specific Complications

• Provide pharmacological treatment with or without dietary intervention when serum bicarbonate <18 mmol/l to prevent metabolic acidosis 3, 1
• Monitor treatment to ensure bicarbonate doesn't exceed the upper limit of normal or adversely affect blood pressure, potassium, or fluid status 3, 1
• Implement an individualized approach for patients with CKD G3-G5 and hyperkalemia, including dietary and pharmacologic interventions 3, 1
• Limit intake of foods rich in bioavailable potassium (e.g., processed foods) for patients with history of hyperkalemia 3, 6
• Screen regularly for symptoms using validated tools, particularly for pain and depression 3, 1
• Address pain using a stepwise approach, starting with non-pharmacological interventions and advancing to pharmacological therapy as needed 3, 1

Medication Management

• Adjust medication dosages according to kidney function 4, 8
• For patients with atrial fibrillation, prefer non-vitamin K antagonist oral anticoagulants (NOACs) over vitamin K antagonists, with appropriate dose adjustments based on GFR 3, 1
• Be aware of potential side effects of medications like losartan, including hyperkalemia, hypotension, and dizziness 5

Special Populations

• For children with CKD, encourage physical activity aiming for 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
• For elderly patients, consider frailty and fall risk when recommending physical activity 2, 3

Referral Considerations

• Consider nephrology referral when 5-year kidney failure risk is 3-5% 4, 9
• Refer patients with rapidly declining kidney function, severe albuminuria, or eGFR <30 ml/min/1.73m² 8, 9
• Utilize multidisciplinary care models to overcome barriers to effective management 2, 9