What is the initial approach to managing a patient with chronic kidney disease (CKD)?

Initial Management of Chronic Kidney Disease

All patients with CKD should be tested using both urine albumin measurement and estimated GFR, then immediately started on a comprehensive treatment strategy that includes lifestyle modification as the foundation, with first-line pharmacologic therapies layered on top according to specific clinical characteristics. 1

Immediate Diagnostic Steps

• Measure both eGFR and urine albumin to detect and stage CKD, as both parameters are required for proper classification and risk stratification 1
• Use the CKD-EPI equation for creatinine-based eGFR estimation in routine practice 2
• Consider cystatin C measurement if factors affecting creatinine accuracy exist (extremes of muscle mass) 2
• Confirm chronicity by repeating abnormal tests after 3 months to distinguish CKD from acute kidney injury 1, 3
• Identify the underlying cause through clinical evaluation (diabetes, hypertension, glomerular disease, etc.) 1

Stage CKD Using the KDIGO Classification

Assign eGFR category (ml/min/1.73 m²): 1

• G1 = ≥90 (with evidence of kidney damage)
• G2 = 60-89 (with evidence of kidney damage)
• G3a = 45-59
• G3b = 30-44
• G4 = 15-29
• G5 = <15

Assign albuminuria category (mg/g): 1

• A1 = <30 (normal to mildly increased)
• A2 = 30-300 (moderately increased)
• A3 = >300 (severely increased)

Foundation: Lifestyle Modifications (All Patients)

• Smoking cessation is mandatory 1
• Dietary counseling focusing on sodium restriction, protein moderation, and potassium management based on stage 1
• Regular physical activity tailored to functional capacity 1
• Weight management targeting BMI <25 kg/m² or weight loss if overweight 1

First-Line Pharmacologic Therapy

For Patients WITH Diabetes and CKD:

Start immediately with this combination: 1

1. SGLT2 inhibitor (initiate if eGFR ≥20 ml/min/1.73 m²; continue until dialysis or transplant) 1
2. Metformin (if eGFR ≥30 ml/min/1.73 m²) 1
3. RAS inhibitor (ACE inhibitor or ARB at maximum tolerated dose if hypertension present) 1, 4
4. Moderate- or high-intensity statin (all patients with diabetes and CKD) 1

For Patients WITHOUT Diabetes and CKD:

Start with: 1, 4

1. ACE inhibitor or ARB if albuminuria present (any stage) or if hypertension present, titrated to maximum approved dose 4
2. Statin for cardiovascular risk reduction 3
3. Blood pressure control targeting <130/80 mmHg 4

Blood Pressure Management Algorithm

Target BP <130/80 mmHg for all CKD patients 4

First-line agent: 4

• ACE inhibitor or ARB (preferred for all CKD patients with hypertension)
• Use maximum approved dose that is tolerated

If BP goal not achieved after 2-4 weeks: 4

• Add either a long-acting dihydropyridine calcium channel blocker OR thiazide-type diuretic

If BP still not controlled: 4

• Add the third agent (CCB or diuretic, whichever not yet used)

Special consideration for Black patients: 4

• Initial therapy should include thiazide-type diuretic or calcium channel blocker, either alone or combined with ACE inhibitor/ARB

Monitoring Schedule After Initiation

Within 2-4 weeks of starting or increasing ACE inhibitor/ARB: 4

• Check serum creatinine (continue medication unless rise >30%) 4
• Check serum potassium 4, 5
• Measure blood pressure 4

Ongoing monitoring frequency based on risk: 1

• G1-G2 with A1: Once yearly
• G3a with A1 or G1-G2 with A2: 2 times per year
• G3b or higher, or A3: 3-4 times per year (every 1-3 months)

Additional Risk-Based Therapies for Diabetes and CKD

If glycemic targets not met with SGLT2i and metformin: 1

• Add GLP-1 receptor agonist (dulaglutide if eGFR >15 ml/min/1.73 m²) 1

If albuminuria ≥30 mg/g persists despite first-line therapy: 1

• Consider nonsteroidal mineralocorticoid receptor antagonist (if potassium normal) 1

If established cardiovascular disease: 1

• Antiplatelet agent for secondary prevention 1

Identify and Eliminate Nephrotoxins

• Discontinue NSAIDs immediately 2, 3
• Review all medications and adjust dosing for renal function 1, 3
• Avoid contrast agents when possible or use lowest effective dose with hydration 3

Nephrology Referral Criteria

Refer immediately if: 1

• eGFR <30 ml/min/1.73 m² 1, 3
• Albuminuria >1 g/day (ACR ≥60 mg/mmol or PCR ≥100 mg/mmol) 1
• Rapid decline in eGFR (>5 ml/min/1.73 m² per year) 3
• Uncertain diagnosis or suspected glomerular disease 1
• Difficulty achieving blood pressure goals despite multiple agents 1
• Persistent electrolyte abnormalities (hyperkalemia, metabolic acidosis) 3

Critical Contraindications and Pitfalls

Never combine ACE inhibitor + ARB + direct renin inhibitor - this increases adverse events without benefit 4

ACE inhibitors and ARBs are absolutely contraindicated in pregnancy 5

Do not discontinue effective antihypertensive therapy simply because BP falls below target if patient tolerates without adverse effects 4

Monitor for and treat CKD complications: 3

• Hyperkalemia (may require potassium binders rather than stopping RAS blockade) 4
• Metabolic acidosis (consider bicarbonate supplementation) 3, 6
• Hyperphosphatemia and vitamin D deficiency 3, 6
• Anemia (check hemoglobin regularly) 3

Patient Education Requirements

Explain to patients: 1

• CKD diagnosis and stage
• Importance of medication adherence
• Dietary modifications specific to their stage
• Need for regular monitoring
• Symptoms requiring immediate attention (volume overload, severe hyperkalemia)
• Progression risks and treatment goals