What are the initial treatment recommendations for patients with Chronic Kidney Disease (CKD)?

Initial Treatment Recommendations for Chronic Kidney Disease

Patients with CKD should be treated with a comprehensive strategy that includes SGLT2 inhibitors as first-line therapy (regardless of diabetes status), RAS inhibition for those with albuminuria, statin therapy for cardiovascular protection, blood pressure control targeting <120 mmHg systolic (using standardized measurement), and lifestyle modifications including sodium restriction to <2 g/day and 150 minutes weekly of moderate-intensity exercise. 1, 2

Foundation: Lifestyle Modifications

All CKD patients require immediate implementation of lifestyle changes as the cornerstone of management:

• Dietary sodium restriction to <2 g sodium per day (<90 mmol/day or <5 g sodium chloride/day) for blood pressure control 1
• Moderate-intensity physical activity for ≥150 minutes per week or to a level compatible with cardiovascular tolerance 1, 2
• Complete smoking cessation is mandatory given the cardiovascular and kidney risks 2
• Weight management targeting optimal body mass index 2
• Mediterranean-style diet to reduce cardiovascular risk and support kidney health 1
• Referral to renal dietitian for individualized nutritional counseling 2

First-Line Pharmacotherapy

SGLT2 Inhibitors (Primary Therapy)

SGLT2 inhibitors should be initiated immediately in all CKD patients (with or without diabetes) when eGFR ≥20 ml/min/1.73 m² and continued until dialysis or transplantation 1. This represents the most significant advancement in CKD management, with proven kidney and cardiovascular protection. Do not delay initiation while optimizing other therapies 2.

Blood Pressure Management

Target systolic blood pressure <120 mmHg using standardized office measurement (not routine office BP, as these values are not interchangeable) 1:

• For patients with albuminuria (A2 or A3): Start RAS inhibitor (ACE inhibitor or ARB) as first-line therapy 1, 2

  • With diabetes and moderately-to-severely increased albuminuria (A2-A3): RAS inhibitor is strongly recommended (1B evidence) 1
  • Without diabetes and severely increased albuminuria (A3): RAS inhibitor is strongly recommended (1B evidence) 1
  • Without diabetes and moderately increased albuminuria (A2): RAS inhibitor is suggested (2C evidence) 1

• For patients without albuminuria: Dihydropyridine calcium channel blocker or diuretic can be used as first-line therapy 1, 2

• Add dihydropyridine CCB and/or diuretic if additional BP control needed to reach target 1, 2

• Monitor blood pressure using 24-hour ambulatory devices when possible for accurate assessment 1, 2

Critical caveat: Accept up to 30% increase in serum creatinine after initiating RAS inhibitors—do not discontinue prematurely 2. Monitor potassium and creatinine within 2-4 weeks of any dose adjustment 3.

Never combine ACE inhibitor, ARB, and direct renin inhibitor together (1B recommendation against) 1.

Lipid Management (Cardiovascular Protection)

For adults ≥50 years with eGFR <60 ml/min/1.73 m² (G3a-G5): Start statin or statin/ezetimibe combination (1A recommendation) 1

For adults ≥50 years with eGFR ≥60 ml/min/1.73 m² (G1-G2): Start statin therapy (1B recommendation) 1

For adults 18-49 years: Suggest statin therapy if any of the following present (2A recommendation) 1:

• Known coronary disease
• Diabetes mellitus
• Prior ischemic stroke
• Estimated 10-year cardiovascular risk >10%

Choose statin regimens to maximize absolute LDL cholesterol reduction 1. Consider PCSK9 inhibitors for patients with indications 1.

Additional Risk-Based Therapy

For Type 2 Diabetes Patients

Metformin when eGFR ≥30 ml/min/1.73 m² 1

GLP-1 receptor agonist if SGLT2 inhibitor and metformin insufficient to meet glycemic targets, or if unable to use SGLT2 inhibitor or metformin 1

Nonsteroidal mineralocorticoid receptor antagonist (finerenone) for patients with persistent albuminuria >30 mg/g (>3 mg/mmol) despite first-line therapy, indicating high residual risk 1

Antiplatelet Therapy

Low-dose aspirin for secondary prevention only in patients with established ischemic cardiovascular disease (1C recommendation) 1. Do not use for primary prevention in CKD given bleeding risks.

Medication Safety

Avoid nephrotoxic medications, particularly NSAIDs 2, 4

Review all medications for appropriate CKD dosing and adjust based on kidney function 2, 4

Monitoring Schedule

Reassess risk factors every 3-6 months including 1, 2:

• Serum creatinine and eGFR
• Potassium levels
• Albuminuria/proteinuria
• Blood pressure (preferably with 24-hour ambulatory monitoring)
• Glycemic control (if diabetic)
• Lipid panel

Common Pitfalls to Avoid

Do not delay SGLT2 inhibitor initiation—these agents have transformative benefits for slowing CKD progression and reducing cardiovascular events 2

Do not discontinue RAS inhibitors for modest creatinine increases (up to 30% acceptable) 2

Do not use routine office BP measurements to guide therapy—standardized BP measurement is required for the <120 mmHg target 1

Do not combine multiple RAS inhibitors (ACE inhibitor + ARB + direct renin inhibitor) 1

Do not overlook modifiable risk factors including smoking, obesity, and sedentary lifestyle 2