What are the initial recommendations for Chronic Kidney Disease (CKD) management?

Initial Management of Chronic Kidney Disease

All patients with newly diagnosed CKD should immediately begin comprehensive management targeting blood pressure control, cardiovascular risk reduction, lifestyle modifications, and medication optimization to prevent disease progression and reduce mortality. 1, 2, 3

Risk Assessment and Diagnostic Confirmation

• Confirm the diagnosis by repeating abnormal tests (elevated ACR, hematuria, or low eGFR) to establish persistence beyond 3 months 2, 3
• Establish the underlying cause through clinical history (including family history, medications, environmental exposures), physical examination, laboratory testing, imaging, and when indicated, genetic or pathologic evaluation 2, 3
• Screen at-risk patients using both urine albumin measurement and eGFR assessment 1, 2, 3
• Apply validated risk prediction tools to guide intensity of management, with 2-year kidney failure risk >10% triggering multidisciplinary care and >40% prompting kidney replacement therapy preparation 2, 3

Blood Pressure Management (First-Line Intervention)

Target blood pressure based on albuminuria status:

• <140/90 mmHg for patients without albuminuria 1, 2, 4
• <130/80 mmHg for patients with albuminuria ≥30 mg/24h 1, 2, 4

Use ACE inhibitors or ARBs as first-line therapy, particularly in patients with albuminuria, and titrate to the highest tolerated dose to maximize kidney protection 1, 2

The American Heart Association recommends even more aggressive control with systolic BP <120 mmHg when tolerated using standardized office measurement, though this should be tempered in patients with frailty, high fall risk, limited life expectancy, or symptomatic orthostatic hypotension 3

Cardiovascular Risk Reduction (Critical for Mortality)

Initiate statin therapy immediately in the following populations:

• All adults ≥50 years with eGFR <60 ml/min/1.73 m² (CKD G3a-G5) should receive statins or statin/ezetimibe combination 1, 2, 3
• Adults ≥50 years with CKD G1-G2 (eGFR ≥60) should receive statins 1
• Adults 18-49 years with coronary disease, diabetes, prior ischemic stroke, or 10-year MI/coronary death risk >10% should receive statins 1, 2, 3

Choose statin regimens that maximize absolute LDL cholesterol reduction to achieve the largest treatment benefit 2, 3

Consider PCSK-9 inhibitors for patients with CKD who have standard indications 1, 3

Prescribe low-dose aspirin for secondary prevention in patients with established ischemic cardiovascular disease 1, 3

Lifestyle Modifications (Non-Negotiable Foundation)

Physical Activity

• Prescribe moderate-intensity physical activity for ≥150 minutes per week, adjusted to cardiovascular and physical tolerance 1, 2, 3
• Counsel patients to avoid sedentary behavior and maintain an active lifestyle 1, 2, 3

Weight Management

• Recommend weight loss for patients with obesity and CKD 1, 2, 3

Smoking Cessation

• Mandate smoking cessation and abstinence from all tobacco products 3

Dietary Management

Advise adoption of healthy, diverse diets emphasizing plant-based foods over animal-based foods and minimizing ultra-processed foods 1, 2, 3

Protein Intake (Stage-Specific)

• Maintain protein at 0.8 g/kg/day in adults with CKD G3-G5 1, 2, 3
• Avoid high protein intake >1.3 g/kg/day in adults with CKD at risk of progression 1, 2, 3
• In highly motivated adults at risk of kidney failure, consider very low-protein diet (0.3-0.4 g/kg/day) supplemented with essential amino acids or ketoacid analogs under close supervision 3

Sodium Restriction

• Limit sodium intake to <2 g per day (or <5 g sodium chloride per day) 3

Medication Management and Safety

Review GFR when dosing all renally-cleared medications, using validated eGFR equations based on serum creatinine for most clinical settings 1, 2, 3

Perform thorough medication reviews periodically and at all care transitions to assess adherence, continued indication, and potential drug interactions 1, 2, 3

Avoid nephrotoxins, particularly NSAIDs 5

Monitor for and manage CKD complications including hyperkalemia, metabolic acidosis, hyperphosphatemia, vitamin D deficiency, secondary hyperparathyroidism, and anemia 5

Specialist Referral Criteria (Time-Sensitive)

Refer immediately to nephrology when any of the following are present:

• ACR ≥30 mg/g (3 mg/mmol) or PCR ≥200 mg/g (20 mg/mmol) 1, 2, 3
• Persistent hematuria 1, 2, 3
• Any sustained decrease in eGFR 1, 2, 3
• eGFR <30 ml/min/1.73 m² or albuminuria ≥300 mg per 24 hours (high risk of progression) 5

Special Populations

Children with CKD

• Encourage physical activity ≥60 minutes daily aiming for WHO-recommended levels and healthy weight achievement 1, 2, 3
• Do NOT restrict protein intake due to risk of growth impairment 1, 2, 3
• Target 24-hour mean arterial pressure ≤50th percentile for age, sex, and height using ambulatory BP monitoring 3

Patients of Childbearing Potential

• Review teratogenicity of all medications and provide regular reproductive and contraceptive counseling 2

Atrial Fibrillation in CKD

• Use NOACs in preference to vitamin K antagonists for thromboprophylaxis in CKD G1-G4, with dose adjustment based on GFR 1, 3