What is the primary management plan for patients with Chronic Kidney Disease (CKD)?

Primary Management of Chronic Kidney Disease

All patients with CKD require a comprehensive, layered treatment strategy built on lifestyle modifications as the foundation, with first-line pharmacologic therapies added based on specific clinical characteristics, followed by additional risk-based interventions to reduce cardiovascular disease and slow kidney disease progression. 1

Foundation: Lifestyle Modifications (All Patients)

Every CKD patient must implement these core interventions 1:

• Physical activity: Undertake moderate-intensity exercise for at least 150 minutes per week, or to a level compatible with cardiovascular and physical tolerance 1
• Dietary modifications: Adopt a plant-based "Mediterranean-style" diet high in vegetables, fruits, whole grains, fiber, legumes, and unsaturated fats 1
• Sodium restriction: Limit intake to <2 grams sodium per day (<5 grams sodium chloride) 2, 3
• Protein intake: Maintain 0.8 g/kg body weight/day for non-dialysis patients; increase to 1.0-1.2 g/kg/day for dialysis patients 2
• Weight management: Achieve optimal body mass index through diet and exercise 1, 4
• Smoking cessation: Complete tobacco cessation is mandatory 1

First-Line Pharmacologic Therapy

Blood Pressure Control

For patients with hypertension and albuminuria, initiate an ACE inhibitor or ARB and titrate to the maximum tolerated dose 1, 2:

• Target BP <130/80 mmHg for patients with diabetes and CKD, or those with albuminuria 1, 2, 5
• Target BP ≤140/90 mmHg for patients without albuminuria 1, 3
• ACE inhibitors and ARBs reduce proteinuria by approximately 34% and slow GFR decline by 13% 6
• Critical caveat: Do not combine ACE inhibitors with ARBs—this increases risks without additional benefits 2
• Accept serum creatinine increases up to 30% after initiation if no volume depletion is present 2

Lipid Management

All adults ≥50 years with eGFR <60 mL/min/1.73 m² should receive statin or statin/ezetimibe combination therapy 1:

• For eGFR ≥60 mL/min/1.73 m² (G1-G2), use statin monotherapy 1
• For adults 18-49 years, initiate statins if they have coronary disease, diabetes, prior stroke, or 10-year cardiovascular risk >10% 1
• Choose statin regimens that maximize absolute LDL cholesterol reduction 1
• Consider PCSK-9 inhibitors for patients with appropriate indications 1

Glycemic Control (Diabetic CKD)

For type 2 diabetes with CKD, the cornerstone is metformin plus SGLT2 inhibitors 1, 2:

• Metformin: Use when eGFR ≥30 mL/min/1.73 m² 1
• SGLT2 inhibitors: Initiate when eGFR ≥20 mL/min/1.73 m² and continue until dialysis or transplantation 1, 2
• GLP-1 receptor agonists: Add if SGLT2i and metformin are insufficient to meet glycemic targets or if patients cannot use these agents 1, 2
• Target HbA1c individualized between <6.5% to <8.0% based on hypoglycemia risk 2

Additional Risk-Based Therapies

For Type 2 Diabetes with Persistent Albuminuria

Add nonsteroidal mineralocorticoid receptor antagonist (ns-MRA) if albumin-to-creatinine ratio ≥30 mg/g with normal potassium 1:

• This applies to patients with high residual risk despite first-line therapy 1
• Monitor potassium closely; if hyperkalemia develops, moderate potassium intake, initiate diuretics, or use gastrointestinal cation exchangers 2

Cardiovascular Disease Prevention

Use low-dose aspirin for secondary prevention in all patients with established cardiovascular disease 1:

• For primary prevention, consider aspirin only in high-risk individuals, balancing against bleeding risk 1
• Use P2Y12 inhibitors if aspirin intolerance exists 1

Monitoring Strategy

Reassess risk factors every 3-6 months 1:

• Monitor urinary albumin-to-creatinine ratio (UACR) regularly 2
• Check eGFR at least annually, more frequently with advancing CKD 2, 7
• Monitor for complications: hyperkalemia, metabolic acidosis, hyperphosphatemia, anemia, and CKD-mineral bone disorders 1, 7

Nephrology Referral Criteria

Refer immediately when 2, 7:

• eGFR <30 mL/min/1.73 m² 2
• Uncertain etiology of kidney disease 2
• Rapidly progressing kidney disease (>5 mL/min/1.73 m² decline per year) 7
• Difficult management issues or persistent albuminuria despite optimal therapy 2

Critical Pitfalls to Avoid

• Never discontinue RAS inhibitors for minor creatinine increases (≤30%) without volume depletion 2
• Never use ACE inhibitors or ARBs for primary prevention in diabetic patients with normal BP, normal UACR (<30 mg/g), and normal eGFR 2
• Never combine ACE inhibitors with ARBs—this increases adverse events without benefit 2
• Never delay nephrology referral for patients meeting criteria above 2
• Never use NSAIDs in CKD patients—these are nephrotoxic and accelerate progression 7
• Always adjust medication dosing as eGFR declines, particularly antibiotics and oral hypoglycemic agents 7

The 2022 KDIGO guidelines represent the most current evidence-based approach, emphasizing that this layered strategy significantly increases median life expectancy and reduces need for dialysis and transplantation 2. The key is avoiding therapeutic inertia—most patients require multiple simultaneous interventions to adequately reduce their high residual cardiovascular and kidney progression risks 1.