What is the management approach for a patient with Chronic Kidney Disease (CKD)?

Management of Chronic Kidney Disease

All patients with CKD should receive a comprehensive, multi-pronged treatment strategy that includes blood pressure control with RAS blockade (if albuminuria and hypertension are present), statin therapy for cardiovascular protection, lifestyle modifications including exercise and dietary sodium restriction, and regular monitoring for metabolic complications—this approach reduces both kidney disease progression and cardiovascular mortality. 1

Core Pharmacologic Interventions

Renin-Angiotensin System Blockade

• Initiate an ACE inhibitor or ARB in all patients with diabetes, hypertension, AND albuminuria (albumin-creatinine ratio >30 mg/g), titrating to the highest approved tolerated dose. 1
• For patients with diabetes, albuminuria, but normal blood pressure, RAS blockade may still be considered given the strong association between albuminuria and disease progression. 1
• Monitor serum creatinine and potassium within 2-4 weeks of initiation or dose changes. 1
• Never combine ACE inhibitors with ARBs—this combination is harmful in CKD patients. 1
• For patients with diabetes, hypertension, but normal albumin excretion, RAS inhibitors have not proven kidney-protective, and other antihypertensives may be equally effective. 1

Blood Pressure Targets

• For CKD patients without albuminuria (<30 mg/24h): target BP <140/90 mmHg. 1, 2
• For patients with albuminuria ≥30 mg/24h: target BP <130/80 mmHg. 1, 2, 3
• Add dihydropyridine calcium channel blockers and/or diuretics as needed to achieve targets. 2
• Regularly check for postural hypotension when treating with BP-lowering drugs. 1, 2

Cardiovascular Risk Reduction

• Prescribe a statin or statin/ezetimibe combination for all adults ≥50 years with eGFR <60 ml/min/1.73 m² (CKD G3a-G5). 1, 2
• For adults ≥50 years with eGFR ≥60 ml/min/1.73 m² (CKD G1-G2), prescribe a statin. 1
• For adults aged 18-49 years, prescribe statins if they have known coronary disease, diabetes, prior ischemic stroke, or estimated 10-year coronary event risk >10%. 1, 2
• Choose statin-based regimens that maximize absolute LDL cholesterol reduction. 1
• Consider PCSK-9 inhibitors for patients with CKD who have an indication for their use. 1
• Use low-dose aspirin for secondary prevention in patients with established ischemic cardiovascular disease. 1, 2

Diabetes Management (if applicable)

• Use metformin as first-line therapy when eGFR ≥30 ml/min/1.73 m². 1, 2
• Initiate SGLT2 inhibitors when eGFR ≥20 ml/min/1.73 m² and continue until dialysis or transplantation. 1, 2
• Consider GLP-1 receptor agonists if SGLT2 inhibitors and metformin are insufficient or cannot be used. 1
• Target hemoglobin A1c of approximately 7%. 2

Lifestyle Modifications

Physical Activity

• Recommend moderate-intensity physical activity for at least 150 minutes per week, adjusted to cardiovascular and physical tolerance. 1, 2, 3
• Advise patients to avoid sedentary behavior. 1, 2, 3
• For patients at higher risk of falls, provide specific advice on exercise intensity (low, moderate, or vigorous) and type (aerobic vs. resistance). 1

Dietary Interventions

• Reduce sodium intake to <2 g per day (<90 mmol/day) to control blood pressure and reduce proteinuria. 2, 4
• Maintain protein intake at 0.8 g/kg body weight/day for adults with CKD G3-G5. 2, 3
• Avoid high protein intake (>1.3 g/kg/day) in adults with CKD at risk of progression. 2, 3
• Recommend a plant-based "Mediterranean-style" diet with higher consumption of plant-based foods and lower consumption of ultra-processed foods. 1, 2, 3
• Limit foods with high potassium content in patients with history of hyperkalemia. 2, 3

Other Lifestyle Factors

• Strongly advise smoking cessation—tobacco use accelerates CKD progression. 1, 2
• Encourage weight loss for patients with obesity and CKD. 1, 2, 3

Monitoring and Risk Assessment

Disease Progression Monitoring

• Monitor eGFR and albuminuria every 3-6 months based on individual risk. 2
• A decline in eGFR of >30% on subsequent testing exceeds expected variability and warrants evaluation. 1
• A doubling of albumin-creatinine ratio on subsequent testing exceeds laboratory variability and warrants evaluation. 1

Risk Prediction

• Use externally validated risk equations to estimate absolute risk of kidney failure in patients with CKD G3-G5. 1
• A 5-year kidney failure risk of 3-5% can determine need for nephrology referral. 1, 2
• A 2-year kidney failure risk >10% can determine timing of multidisciplinary care. 1, 2, 3
• A 2-year kidney failure risk >40% can determine timing of kidney replacement therapy preparation. 1, 2, 3
• For cardiovascular risk prediction, use externally validated models that incorporate eGFR and albuminuria. 1, 3

Management of Metabolic Complications

Acidosis

• Provide pharmacological treatment with or without dietary intervention to prevent acidosis (serum bicarbonate <18 mmol/L). 2, 3
• Monitor treatment to ensure serum bicarbonate doesn't exceed normal limits and doesn't negatively impact blood pressure, serum potassium, or fluid balance. 2, 3

Hyperkalemia

• Implement an individualized approach including dietary and pharmacologic interventions for patients with CKD G3-G5 and hyperkalemia. 2
• Be aware of factors affecting potassium measurement including diurnal variation, sample type, and medication effects. 2

Hyperuricemia

• Treat symptomatic hyperuricemia (gout) with urate-lowering therapy, preferring xanthine oxidase inhibitors over uricosuric agents. 3
• Do not prescribe urate-lowering agents for asymptomatic hyperuricemia to delay CKD progression. 1, 3

Medication Management

Dose Adjustments

• Adjust medication dosages according to kidney function. 2, 3
• Avoid nephrotoxins including NSAIDs, proton-pump inhibitors (when possible), and iodinated contrast. 5, 6

Anticoagulation (if atrial fibrillation present)

• Prefer non-vitamin K antagonist oral anticoagulants (NOACs) over vitamin K antagonists, with appropriate dose adjustments based on GFR. 2, 3
• Use opportunistic pulse-based screening for atrial fibrillation when measuring blood pressure. 1

Deprescribing

• Implement deprescribing protocols to reduce pill burden and avoid potentially inappropriate medications. 2

Symptom Management

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

Referral Criteria

• Promptly refer to nephrology if eGFR <30 ml/min/1.73 m², albuminuria ≥300 mg per 24 hours, or rapid decline in eGFR. 5
• Consider nephrology referral when 5-year kidney failure risk is 3-5%, in addition to eGFR and albuminuria criteria. 1, 2

Special Populations: Children with CKD

• Encourage physical activity aiming for ≥60 minutes daily and achievement of healthy weight. 2, 3
• Do not restrict protein intake in children with CKD due to risk of growth impairment. 2, 3

Common Pitfalls to Avoid

• Do not discontinue RAS inhibitors prematurely when serum creatinine rises—continue unless creatinine rises by more than 30% within 4 weeks of initiation. 1
• Do not combine ACE inhibitors with ARBs. 1
• Avoid aggressive blood pressure lowering in elderly patients without considering postural hypotension risk. 1
• Do not overlook cardiovascular risk—CKD patients have markedly elevated cardiovascular mortality that requires aggressive management. 1