What are the management strategies for chronic kidney disease (CKD)?

Management of Chronic Kidney Disease

Core Treatment Strategy

Treat all CKD patients with a comprehensive strategy combining lifestyle modifications, blood pressure control, cardiovascular risk reduction, and disease-specific pharmacotherapy to reduce progression and complications. 1

Blood Pressure Management

Target blood pressure ≤140/90 mmHg for patients without albuminuria (<30 mg/24h), and ≤130/80 mmHg for those with albuminuria ≥30 mg/24h. 1, 2

First-Line Antihypertensive Therapy

• Use ACE inhibitors or ARBs as first-line agents for all patients with albuminuria >300 mg/24h 1, 2
• For patients with albuminuria 30-300 mg/24h, ACE inhibitors or ARBs are also recommended 1
• Add dihydropyridine calcium channel blockers and/or diuretics to achieve blood pressure targets 2
• Monitor for postural hypotension regularly when treating with blood pressure-lowering drugs 1

Critical pitfall: Do not discontinue ACE inhibitors or ARBs due to small increases in creatinine (up to 30% is acceptable and does not indicate harm) 1

Lifestyle Modifications

Physical Activity

• Prescribe moderate-intensity physical activity for at least 150 minutes per week, adjusted to cardiovascular tolerance 1, 2
• Advise patients to avoid sedentary behavior 1
• For patients at high fall risk, provide specific guidance on exercise intensity (low, moderate, or vigorous) and type (aerobic vs. resistance) 1

Weight Management

• Encourage weight loss in patients with obesity and CKD 1, 2
• Target optimal body mass index through dietary modifications and physical activity 1

Smoking Cessation

• Strongly encourage all patients to stop using tobacco products, as smoking accelerates CKD progression 1, 3

Dietary Management

Protein Intake

• Maintain protein intake at 0.8 g/kg body weight/day for adults with CKD G3-G5 1, 2
• Avoid high protein intake (>1.3 g/kg/day) in patients at risk of progression 1, 4
• For highly motivated patients at risk of kidney failure, consider very low-protein diets (0.3-0.4 g/kg/day) supplemented with essential amino acids or ketoacid analogs under close supervision 1
• Do not prescribe low-protein diets in metabolically unstable patients 1

Pediatric exception: Never restrict protein in children with CKD due to growth impairment risk; target the upper end of normal range 1

Sodium Restriction

• Limit sodium intake to <2 g per day (<90 mmol/day or <5 g sodium chloride/day) 1, 2
• Exception: Do not restrict sodium in patients with sodium-wasting nephropathy 1

Overall Dietary Pattern

• Recommend plant-based diets with higher consumption of plant-based foods compared to animal-based foods and lower consumption of ultraprocessed foods 1, 2
• Refer patients to renal dietitians for individualized education on sodium, phosphorus, potassium, and protein intake 1, 4

Cardiovascular Risk Reduction

Statin Therapy

• Prescribe statins for all adults aged ≥50 years with CKD regardless of GFR category 2, 4
• For adults aged 18-49 years, prescribe statins if they have coronary disease, diabetes, prior stroke, or 10-year coronary event risk >10% 2, 4
• Add ezetimibe based on ASCVD risk and lipid levels 2, 4

Antiplatelet Therapy

• Consider antiplatelet therapy for patients with established cardiovascular disease 2, 4

Glycemic Control in Diabetic CKD

For diabetic patients with CKD, implement a multi-drug approach targeting hemoglobin A1c of approximately 7%. 2, 5

Medication Algorithm

1. Start with metformin when eGFR ≥30 ml/min/1.73m² 2, 4
2. Add SGLT2 inhibitors when eGFR ≥20 ml/min/1.73m² and continue until dialysis or transplantation 2, 4, 6
3. Consider GLP-1 receptor agonists when SGLT2 inhibitors and metformin are insufficient 2

Key evidence: SGLT2 inhibitors slow CKD progression and reduce complications independent of glycemic control, making them essential therapy even in non-diabetic CKD 6

Management of CKD-Specific Complications

Metabolic Acidosis

• Provide pharmacological treatment with or without dietary intervention when serum bicarbonate <18 mmol/L 2, 4
• Monitor to ensure bicarbonate doesn't exceed normal limits or adversely affect blood pressure, potassium, or fluid status 2, 4

Hyperkalemia

• Implement dietary interventions limiting foods rich in bioavailable potassium (especially processed foods) 2
• Use pharmacologic interventions as needed for patients with CKD G3-G5 and hyperkalemia 2, 4
• Be aware that diurnal variation, sample type, and medications affect potassium measurements 2, 4

Anemia Management

• Evaluate iron status before and during treatment; supplement when ferritin <100 mcg/L or transferrin saturation <20% 7
• For CKD patients on dialysis, initiate erythropoiesis-stimulating agents (ESAs) when hemoglobin <10 g/dL 7
• Target the lowest hemoglobin level sufficient to reduce RBC transfusions; do not target hemoglobin >11 g/dL due to increased cardiovascular risks and mortality 7

Monitoring and Risk Assessment

• Monitor kidney function every 3-6 months using both blood and urine tests, with frequency guided by individual risk 2, 4
• Use validated risk prediction tools to guide management decisions 4, 5
• Consider all CKD patients at increased risk for acute kidney injury 2, 4
• Recognize that small GFR fluctuations are common and don't necessarily indicate progression 4, 5

Symptom Management

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

Referral to Specialists

• Refer to renal dietitians or accredited nutrition providers for dietary education tailored to individual needs 1, 2
• Consider referral to psychologists, pharmacists, and physical therapy as indicated 1
• Refer to nephrology when eGFR <30 ml/min/1.73m², albuminuria ≥300 mg/24h, or rapid GFR decline 8

Special Population Considerations

Pediatric Patients

• Encourage 60 minutes of daily physical activity 1, 2
• Target protein and energy intake at the upper end of normal range to promote optimal growth 1
• Never restrict protein due to growth impairment risk 1, 4

Older Adults

• Provide specific advice on exercise intensity for patients at high fall risk 1, 4
• Consider higher protein and calorie targets in patients with frailty and sarcopenia 1