What are the steps in managing complications of Chronic Kidney Disease (CKD)?

Schematic Diagram of CKD Complications Management

The management of CKD complications requires a systematic approach focusing on risk assessment, lifestyle modifications, pharmacological interventions, and targeted therapies for specific complications to reduce morbidity and mortality.

Step 1: Regular Risk Assessment and Monitoring

• Monitor progression of CKD using both blood and urine tests regularly (every 3-6 months), with frequency guided by individual risk 1
• Assess GFR and albuminuria to stratify risk and guide therapy 1, 2
• Use validated risk equations to estimate absolute risk of kidney failure to determine timing of referral for multidisciplinary care 1
• Recognize that small fluctuations in GFR are common and do not necessarily indicate progression 1, 2

Step 2: Lifestyle Interventions

• Implement moderate-intensity physical activity for at least 150 minutes per week 2
• Encourage smoking cessation as tobacco use accelerates CKD progression 2
• Target optimal body weight with weight loss recommendations for patients with obesity 2
• Recommend plant-based diets with protein intake of 0.8 g/kg body weight/day for adults with CKD G3-G5 2, 1
• Reduce sodium intake to <2 g per day to help control blood pressure and reduce proteinuria 2, 1

Step 3: Blood Pressure Management

• Target blood pressure ≤140/90 mmHg for patients with urine albumin excretion <30 mg/24 hours 1, 3
• Aim for more intensive control with target ≤130/80 mmHg for patients with albuminuria ≥30 mg/24 hours 1, 3
• Use ACE inhibitors or ARBs as first-line therapy, especially if albuminuria is present 1
• Add dihydropyridine calcium channel blockers and/or diuretics as needed to achieve blood pressure targets 1, 3
• Consider nonsteroidal mineralocorticoid receptor antagonists in people with diabetes 1, 3

Step 4: Glycemic Control in Diabetic CKD

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

Step 5: Cardiovascular Risk Reduction

• Prescribe statins for all adults aged ≥50 years with CKD regardless of GFR category 2, 3
• Recommend statin therapy for adults aged 18-49 years with CKD if they have coronary disease, diabetes, prior stroke, or elevated cardiovascular risk 2
• Add ezetimibe based on ASCVD risk and lipid levels 2, 3
• Consider antiplatelet therapy for patients with established cardiovascular disease 1, 2

Step 6: Management of Metabolic Acidosis

• Consider pharmacological treatment with or without dietary intervention when serum bicarbonate <18 mmol/l 2
• Monitor treatment to ensure bicarbonate doesn't exceed the upper limit of normal 2
• Avoid adverse effects on blood pressure, potassium, or fluid status when treating acidosis 2

Step 7: Management of Hyperkalemia

• Implement an individualized approach for patients with CKD G3-G5 and hyperkalemia 2
• Limit intake of foods rich in bioavailable potassium (e.g., processed foods) 2
• Be aware of factors affecting potassium measurement including diurnal variation, sample type, and medication effects 2

Step 8: Management of Anemia

• Evaluate iron status in all patients before and during treatment 4
• Administer supplemental iron therapy when serum ferritin is less than 100 mcg/L or when serum transferrin saturation is less than 20% 4
• For patients with CKD on dialysis, initiate erythropoiesis-stimulating agents (ESAs) when hemoglobin level is less than 10 g/dL 4
• For patients with CKD not on dialysis, consider initiating ESAs only when hemoglobin level is less than 10 g/dL and risk of requiring RBC transfusion exists 4
• Use the lowest ESA dose sufficient to reduce the need for RBC transfusions 4

Step 9: Management of CKD-Mineral Bone Disorder

• Monitor calcium, phosphorus, PTH, and vitamin D levels regularly 1, 2
• Treat hyperphosphatemia with dietary phosphate restriction and phosphate binders 2
• Address vitamin D deficiency and secondary hyperparathyroidism 2

Step 10: Symptom Management

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

Step 11: Referral to Specialists

• Refer patients to renal dietitians or accredited nutrition providers for dietary education 2
• Consider referral to nephrology for patients with eGFR <45 ml/min/1.73 m² 3
• Immediate nephrology referral is warranted for uncertainty about etiology, difficult management issues, or rapidly progressing kidney disease 3

Step 12: Medication Review and Optimization

• Review and limit use of over-the-counter medicines and dietary/herbal remedies that may be harmful 3
• Avoid nephrotoxic medications including NSAIDs 3
• Consider GFR when dosing medications cleared by the kidneys 3
• Perform thorough medication review periodically and at transitions of care 3

Step 13: Preparation for Kidney Replacement Therapy

• Use validated risk equations to determine timing for modality education and preparation for transition to kidney replacement therapy 1
• Consider both dialysis and transplantation options 1
• Implement multidisciplinary care for patients approaching kidney failure 1