What is the recommended treatment for a patient with chronic kidney disease?

Prescription for Chronic Kidney Disease

For a patient with chronic kidney disease, prescribe an ACE inhibitor or ARB (at maximum tolerated dose) combined with an SGLT2 inhibitor, a statin (or statin/ezetimibe), target blood pressure <120 mmHg systolic, and restrict dietary sodium to <2 g/day. 1

Core Pharmacotherapy

Renin-Angiotensin System Inhibition

• Start an ACE inhibitor or ARB for all patients with moderately-to-severely increased albuminuria (A2-A3), regardless of diabetes status 1
• Use the highest approved dose tolerated to achieve maximum benefit, as trial benefits were demonstrated at these doses 1
• Continue therapy even when eGFR falls below 30 ml/min per 1.73 m² unless specific contraindications arise 1
• Check BP, serum creatinine, and potassium within 2-4 weeks of initiation or dose increase 1
• Do not combine ACE inhibitors with ARBs or direct renin inhibitors—this combination is contraindicated 1

Key monitoring thresholds:

• Continue therapy unless creatinine rises >30% within 4 weeks of initiation 1
• Manage hyperkalemia with potassium-lowering measures rather than stopping RASi when possible 1
• Consider dose reduction only for symptomatic hypotension, uncontrolled hyperkalemia despite treatment, or uremic symptoms with eGFR <15 1

SGLT2 Inhibitors

• Prescribe an SGLT2 inhibitor for all patients with type 2 diabetes and eGFR ≥20 ml/min per 1.73 m² (1A recommendation) 1
• Also prescribe for non-diabetic CKD patients with eGFR ≥20 and ACR ≥200 mg/g, or those with heart failure regardless of albuminuria 1
• Continue SGLT2i even if eGFR falls below 20 after initiation, unless not tolerated or dialysis starts 1
• Withhold temporarily during prolonged fasting, surgery, or critical illness due to ketosis risk 1
• The reversible eGFR decrease on initiation is not an indication to discontinue 1

Nonsteroidal Mineralocorticoid Receptor Antagonists

• Consider adding finerenone for patients with type 2 diabetes, eGFR >25, normal potassium, and persistent albuminuria >30 mg/g despite maximum RASi 1
• This can be added on top of both RASi and SGLT2i for high-risk patients 1
• Initiate only if baseline potassium ≤4.8 mmol/L 1
• Dosing: 10 mg daily if eGFR 25-59; 20 mg daily if eGFR ≥60 1
• Hold if potassium >5.5 mmol/L; continue if 4.9-5.5 mmol/L with monitoring every 4 months 1

Lipid Management

• Prescribe a statin or statin/ezetimibe combination for all adults ≥50 years with eGFR <60 ml/min per 1.73 m² (1A recommendation) 1
• Prescribe a statin for all adults ≥50 years with eGFR ≥60 1
• For adults 18-49 years, prescribe statins if they have diabetes, known coronary disease, prior stroke, or 10-year CV risk >10% 1
• Choose regimens that maximize absolute LDL reduction for greatest benefit 1
• Consider PCSK-9 inhibitors for patients with appropriate indications 1

Blood Pressure Management

Target and Monitoring

• Target systolic BP <120 mmHg using standardized office measurement when tolerated 1
• Use less intensive targets for patients with frailty, high fall risk, limited life expectancy, or symptomatic orthostatic hypotension 1
• Consider 24-hour ambulatory BP monitoring for accurate assessment 1

Antihypertensive Strategy

• Start with ACE inhibitor or ARB as first-line (addresses both BP and kidney protection) 1
• Add a diuretic as second-line therapy, particularly for salt-sensitive or hypervolemic patients 1
• Higher loop diuretic doses and twice-daily dosing are more effective in reduced GFR 2
• Consider thiazide-like diuretics (chlorthalidone) for stage 4 CKD with uncontrolled hypertension 3
• Add calcium channel blockers, beta-blockers, or other agents as needed to reach target 1

Dietary Interventions

Sodium Restriction

• Restrict sodium intake to <2 g/day (<90 mmol/day or <5 g sodium chloride/day) 1, 2
• This enhances diuretic efficacy and improves BP control 1, 2
• Exception: Do not restrict in sodium-wasting nephropathy 1

Dietary Pattern

• Recommend a plant-based Mediterranean-style diet to reduce cardiovascular risk 1
• This complements lipid-modifying therapy 1

Cardiovascular Protection

Antiplatelet Therapy

• Prescribe low-dose aspirin only for secondary prevention in patients with established ischemic cardiovascular disease 1
• Consider P2Y12 inhibitors if aspirin intolerance 1
• Do not use aspirin for primary prevention in CKD 1

Atrial Fibrillation Management

• Prescribe NOACs (non-vitamin K antagonist oral anticoagulants) over warfarin for thromboprophylaxis in CKD G1-G4 with atrial fibrillation 1
• Dose adjustment based on GFR is required, with particular caution in CKD G4-G5 1

Common Pitfalls to Avoid

Do not discontinue RASi prematurely:

• A creatinine rise <30% is expected and acceptable 1
• Hyperkalemia should be managed medically first, not by stopping RASi 1
• Continue even with advanced CKD (eGFR <30) unless specific contraindications 1

Do not underdose proven therapies:

• RASi should be titrated to maximum approved doses 1
• Statins should maximize LDL reduction 1

Do not overlook SGLT2i in non-diabetics:

• Strong 1A recommendation for albuminuric CKD or heart failure regardless of diabetes status 1

Do not combine ACEi + ARB:

• This combination is contraindicated and increases harm 1

Monitor potassium carefully when adding MRA:

• Only initiate if baseline K+ ≤4.8 mmol/L 1
• Check at 1 month, then every 4 months 1