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

Treatment Options for Chronic Kidney Disease

Treat all CKD patients with SGLT2 inhibitors as first-line drug therapy for most patients, combined with comprehensive blood pressure control targeting <120 mmHg systolic, statin-based lipid therapy, and lifestyle modifications including at least 150 minutes weekly of moderate-intensity physical activity. 1, 2

First-Line Pharmacologic Therapy

SGLT2 Inhibitors

• Initiate SGLT2 inhibitors as foundational therapy for most CKD patients, regardless of diabetes status, as they provide kidney protection, heart protection, and reduce CKD progression 1, 3
• Continue SGLT2 inhibitors until dialysis or transplantation 1

Blood Pressure Management

• Target systolic blood pressure <120 mmHg for optimal kidney and cardiovascular protection 1
• Use RAS inhibitors (ACE inhibitors or ARBs) at maximum tolerated dose as first-line therapy when albuminuria is present 1, 2
• Add dihydropyridine calcium channel blockers and/or diuretics to achieve blood pressure targets when needed 1, 3
• For patients without albuminuria, target <140/90 mmHg; with albuminuria ≥30 mg/24h, target <130/80 mmHg 2, 3

Lipid Management

• Prescribe statin or statin/ezetimibe combination for all adults ≥50 years with eGFR <60 ml/min/1.73 m² (CKD G3a-G5) 1, 2, 3
• For adults ≥50 years with eGFR ≥60 ml/min/1.73 m² (CKD G1-G2), prescribe statin therapy 1
• Choose statin regimens that maximize absolute LDL cholesterol reduction 1, 2
• Add ezetimibe or PCSK9 inhibitors based on ASCVD risk and lipid levels 1, 3

Targeted Therapies for Specific Conditions

Diabetes Management

• Use nonsteroidal mineralocorticoid receptor antagonists (ns-MRA) in people with diabetes 1
• Add GLP-1 receptor agonists where indicated per diabetes guidelines 1
• Manage hyperglycemia according to KDIGO Diabetes Guidelines 1

Resistant Hypertension

• Add steroidal mineralocorticoid receptor antagonists if needed for resistant hypertension 1

Cardiovascular Disease Prevention

• Prescribe low-dose aspirin for secondary prevention in patients with established ischemic cardiovascular disease 1, 2, 3
• For atrial fibrillation, use non-vitamin K antagonist oral anticoagulants (NOACs) in preference to warfarin for CKD G1-G4, with appropriate dose adjustments 1, 2

Lifestyle Modifications

Physical Activity

• Prescribe moderate-intensity physical activity for cumulative duration of at least 150 minutes per week, adjusted to cardiovascular and physical tolerance 1, 2
• Advise patients to avoid sedentary behavior 1, 2
• For children with CKD, recommend ≥60 minutes daily of physical activity 1, 2

Weight Management

• Encourage weight loss for patients with obesity and CKD 1, 2
• Target optimal body mass index through diet and exercise 1, 2

Tobacco Cessation

• Advise all patients to stop using tobacco products 1, 2

Dietary Interventions

General Dietary Principles

• Adopt healthy, diverse diets with higher consumption of plant-based foods compared to animal-based foods and lower consumption of ultraprocessed foods 1, 2
• Consider plant-based "Mediterranean-style" diet to reduce cardiovascular risk 1, 2, 3

Protein Intake

• Maintain protein intake of 0.8 g/kg body weight/day in adults with CKD G3-G5 1, 2, 3
• Avoid high protein intake (>1.3 g/kg body weight/day) in adults at risk of CKD progression 1, 2
• For willing and able patients at high risk of kidney failure, consider very low-protein diet (0.3-0.4 g/kg body weight/day) with essential amino acid or ketoacid supplementation under close supervision 1, 2
• Never restrict protein in patients who are cachexic, sarcopenic, or undernourished 1
• Do not restrict protein in children with CKD due to growth impairment risk 2

Sodium and Other Minerals

• Use renal dietitians to educate patients about dietary adaptations for sodium, phosphorus, potassium, and protein intake 1, 2
• Limit foods with high potassium content in patients with history of hyperkalemia 2

Management of CKD Complications

Metabolic Complications

• Manage anemia, CKD-mineral and bone disorder, acidosis, and potassium abnormalities where indicated 1
• Provide pharmacological treatment with or without dietary intervention to prevent acidosis (serum bicarbonate <18 mmol/L) 2
• Monitor treatment to ensure serum bicarbonate doesn't exceed normal limits or negatively impact blood pressure, potassium, or fluid balance 2

Hyperuricemia and Gout

• Treat symptomatic hyperuricemia (gout) with xanthine oxidase inhibitors in preference to uricosuric agents 1, 2
• For acute gout, use low-dose colchicine or intra-articular/oral glucocorticoids rather than NSAIDs 1
• Do not prescribe urate-lowering therapy for asymptomatic hyperuricemia to delay CKD progression 1, 2
• Recommend limiting alcohol, meats, and high-fructose corn syrup intake for gout prevention 1, 2

Medication Safety

Nephrotoxin Avoidance

• Avoid nephrotoxic medications including NSAIDs 3, 4
• Review and limit over-the-counter medicines and dietary/herbal remedies that may be harmful 3
• Adjust medication dosages according to kidney function 2, 3, 4

Regular Medication Review

• Perform thorough medication review periodically and at transitions of care to assess adherence, continued indications, and potential drug interactions 3

Monitoring and Risk Assessment

Regular Reassessment

• Conduct regular risk factor reassessment every 3-6 months 1
• Monitor eGFR, electrolytes, and therapeutic medication levels approximately every 3-5 months for stage G3b CKD 3

Risk Stratification

• Use externally validated risk equations to estimate absolute risk of kidney failure 1, 2, 5
• Consider nephrology referral when 5-year kidney failure risk is 3-5% 1, 2, 5
• Initiate multidisciplinary care when 2-year kidney failure risk exceeds 10% 1, 2, 5
• Begin kidney replacement therapy preparation when 2-year kidney failure risk exceeds 40% 1, 5

Multidisciplinary Care

Referrals and Support Programs

• Refer to renal dietitians or accredited nutrition providers for dietary education 1, 2
• Offer referrals to psychologists, pharmacists, physical and occupational therapy, and smoking cessation programs where indicated and available 1

Common Pitfalls to Avoid

• Do not discontinue RAS inhibitors for serum creatinine increases ≤30% in the absence of volume depletion 3
• Avoid assuming all CKD patients need protein restriction; individualize based on nutritional status 1
• Do not use NSAIDs for acute gout management in CKD patients 1
• Ensure blood pressure targets are achieved through combination therapy rather than accepting suboptimal control 1