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

CKD Treatment Protocols

All patients with CKD should receive SGLT2 inhibitors as first-line therapy for most patients, combined with RAS inhibition (ACE inhibitor or ARB) at maximum tolerated dose when hypertension or albuminuria is present, targeting systolic blood pressure <120 mm Hg, alongside statin-based lipid therapy—this comprehensive approach forms the foundation of modern CKD management according to the 2024 KDIGO guidelines. 1

First-Line Pharmacologic Therapy

Core Drug Regimen for Most Patients

• SGLT2 inhibitors are recommended as first-line therapy for most CKD patients and should be continued until dialysis or transplant 1
• RAS inhibition (ACE inhibitor or ARB) at maximum tolerated dose is first-line when hypertension is present, and mandatory when albuminuria is present 1
• Statin therapy (moderate to high-intensity) is recommended for all adults ≥50 years with eGFR <60 mL/min/1.73 m² (CKD G3a-G5), using statin or statin/ezetimibe combination 1
• For adults 18-49 years with CKD, statins are indicated if they have coronary disease, diabetes, prior ischemic stroke, or >10% 10-year cardiovascular risk 1

Blood Pressure Management Algorithm

• Target SBP <120 mm Hg for most CKD patients 1
• When albuminuria is present: ACE inhibitor or ARB must be first-line 1
• When albuminuria is absent: dihydropyridine calcium channel blocker (CCB) or diuretic can be considered as alternatives 1
• All three drug classes (RAS inhibitor, CCB, diuretic) are often needed to achieve BP targets 1
• Add dihydropyridine CCB and/or diuretic as needed to reach individualized BP target 1

Advanced Pharmacotherapy

• Nonsteroidal mineralocorticoid receptor antagonists (ns-MRA) should be used in patients with diabetes 1
• Steroidal MRA if needed for resistant hypertension 1
• Ezetimibe and PCSK9 inhibitors indicated based on ASCVD risk and lipid levels 1
• Consider PCSK9 inhibitors for CKD patients who have an indication for their use 1

Lifestyle Modifications

Physical Activity Requirements

• 150 minutes per week of moderate-intensity physical activity is recommended, or to a level compatible with cardiovascular and physical tolerance 1
• Avoid sedentary behavior 1
• For patients at higher risk of falls, provide specific advice on intensity (low, moderate, or vigorous) and type of exercises (aerobic vs. resistance) 1
• Children with CKD should aim for WHO-advised levels of 60 minutes daily 1

Dietary Interventions

• Adopt healthy, diverse diets with higher consumption of plant-based foods compared to animal-based foods and lower consumption of ultraprocessed foods 1
• Protein intake of 0.8 g/kg body weight/day should be maintained in adults with CKD G3-G5 1
• Avoid high protein intake (>1.3 g/kg body weight/day) in adults with CKD at risk of progression 1
• Consider plant-based "Mediterranean-style" diet in addition to lipid-modifying therapy 1
• Use renal dietitians for education about dietary adaptations regarding sodium, phosphorus, potassium, and protein intake 1

Weight and Tobacco Management

• Achieve optimal body mass index (BMI) 1
• Physicians should advise/encourage people with obesity and CKD to lose weight 1
• Stop use of all tobacco products 1

Management of Diabetes in CKD

• Manage hyperglycemia as per KDIGO Diabetes Guideline 1
• GLP-1 receptor agonists should be used where indicated 1
• Glycemic control is important in preventing microvascular complications 2

Cardiovascular Disease Management

Antiplatelet Therapy

• Low-dose aspirin is recommended for secondary prevention in CKD patients with established ischemic cardiovascular disease 1
• Consider other antiplatelet therapy (e.g., P2Y12 inhibitors) when aspirin intolerance exists 1

Coronary Artery Disease Approach

• In stable stress-test confirmed ischemic heart disease, initial conservative approach using intensive medical therapy is appropriate as alternative to initial invasive strategy 1
• Initial invasive strategy may still be preferable for acute/unstable coronary disease, unacceptable angina, left ventricular systolic dysfunction from ischemia, or left main disease 1

Atrial Fibrillation Management

• Non-vitamin K antagonist oral anticoagulants (NOACs) are preferred over vitamin K antagonists (warfarin) for thromboprophylaxis in atrial fibrillation in CKD G1-G4 1
• NOAC dose adjustment for GFR is required, with caution needed at CKD G4-G5 1

Management of Metabolic Complications

Hyperuricemia and Gout

• Do NOT use agents to lower serum uric acid in CKD patients with asymptomatic hyperuricemia to delay CKD progression 1
• For symptomatic gout: use urate-lowering therapy, with xanthine oxidase inhibitors preferred over uricosuric agents 1
• Low-dose colchicine or glucocorticoids are preferable to NSAIDs for acute gout management 1, 3
• Limit alcohol, meats, and high-fructose corn syrup intake to prevent gout 1, 3

Anemia, CKD-MBD, Acidosis, and Potassium

• Manage anemia, CKD-mineral and bone disorder (CKD-MBD), acidosis, and potassium abnormalities where indicated 1

Monitoring and Reassessment

• Regular risk factor reassessment every 3-6 months 1
• Estimate 10-year cardiovascular risk using a validated risk tool 1

Critical Pitfalls to Avoid

• Never prescribe NSAIDs in CKD due to nephrotoxicity risk and potential for acute kidney injury—use low-dose colchicine or glucocorticoids instead for inflammatory conditions 1, 3
• Do not use urate-lowering therapy for asymptomatic hyperuricemia as it does not delay CKD progression 1
• Avoid high protein intake (>1.3 g/kg/day) as it accelerates progression 1
• Do not overlook statin therapy—cardiovascular disease is the leading cause of mortality in CKD 3
• Ensure medication dose adjustments according to kidney function 4

Referral Strategy

• Refer to renal dietitians, pharmacists, physical/occupational therapy, and smoking cessation programs where indicated and available 1