Treatment for Slowing Down CKD Progression
Start with ACE inhibitors or ARBs for patients with albuminuria ≥30 mg/g, optimize blood pressure to ≤130/80 mmHg if albuminuria is present, add SGLT2 inhibitors for diabetic CKD patients with eGFR ≥20 mL/min/1.73 m², and implement strict glycemic control in diabetic patients. 1, 2
Primary Pharmacologic Interventions
RAAS Blockade (First-Line Therapy)
ACE inhibitors or ARBs are the cornerstone of CKD treatment for patients with albuminuria. 1, 2
- For moderately increased albuminuria (30-299 mg/g): ACE inhibitor or ARB is recommended 1
- For severely increased albuminuria (≥300 mg/g) and/or eGFR <60 mL/min/1.73 m²: ACE inhibitor or ARB is strongly recommended to prevent kidney disease progression and reduce cardiovascular events 1
- These agents reduce proteinuria and consistently slow progression in both diabetic and non-diabetic nephropathy 2
Critical monitoring caveat: Do not discontinue RAAS blockade for minor creatinine increases ≤30% in the absence of volume depletion 1. Monitor serum creatinine and potassium periodically when using these agents 1. Avoid dual RAAS blockade (combining ACE inhibitor + ARB) as the VA NEPHRON-D trial showed increased hyperkalemia and acute kidney injury without additional benefit 3.
SGLT2 Inhibitors (Essential for Diabetic CKD)
For type 2 diabetes with diabetic kidney disease, SGLT2 inhibitors are highly effective and should be added when eGFR ≥20 mL/min/1.73 m². 1, 4
- Use in patients with urinary albumin ≥200 mg/g creatinine to reduce CKD progression and cardiovascular events 1
- Continue until dialysis or transplantation 4
- Recent evidence shows these are among the most effective treatments for slowing progression in diabetic CKD 5
Nonsteroidal Mineralocorticoid Receptor Antagonist
Finerenone is recommended for patients at increased cardiovascular or CKD progression risk who cannot use SGLT2 inhibitors. 1
- Particularly useful in patients with chronic kidney disease and urine albumin ranging from normal to 200 mg/g creatinine 1
Blood Pressure Management
Target BP ≤130/80 mmHg for patients with albuminuria ≥30 mg/24 hours. 2, 4
- For patients with urine albumin excretion <30 mg/24 hours, target BP ≤140/90 mmHg 2, 4
- Blood pressure control and reducing BP variability are critical to slow CKD progression 1, 6
- Add dihydropyridine calcium channel blockers and/or diuretics as needed to achieve targets 4
Important note: Patients with ACR ≥300 mg/g are more likely to have uncontrolled BP despite taking antihypertensive medication, requiring more aggressive management 6.
Glycemic Control (For Diabetic CKD)
Optimize glucose management to reduce risk and slow CKD progression, targeting HbA1c approximately 7%. 1, 4
- Metformin: First-line when eGFR ≥30 mL/min/1.73 m² 4
- SGLT2 inhibitors: Add when eGFR ≥20 mL/min/1.73 m² 4
- GLP-1 receptor agonists: Consider when SGLT2 inhibitors and metformin are insufficient 4
- Glycemic control is important for preventing microvascular complications and may help reduce albuminuria 5
Lifestyle and Dietary Interventions
Dietary Modifications
Limit protein intake to maximum 0.8 g/kg body weight/day for stage 3 or higher CKD. 1, 4
- Sodium restriction: Reduce to <2 g per day to control BP and reduce proteinuria 2, 4
- Mediterranean-style diet: Recommended to reduce cardiovascular risk 2
- Avoid high protein intake >1.3 g/kg/day in those at risk of progression 4
Physical Activity and Weight Management
Engage in moderate-intensity physical activity for at least 150 minutes per week. 4
- Target optimal body weight with weight loss for patients with obesity 4
- Avoid sedentary behavior 4
- Walking and weight loss have been shown to slow CKD progression 7
Smoking and Alcohol
Encourage smoking cessation as tobacco accelerates CKD progression. 4
- Avoid binge alcohol drinking which increases risk of progression 7
Cardiovascular Risk Reduction
Prescribe statins for all adults aged ≥50 years with CKD regardless of GFR category. 4
- For adults 18-49 years, use statins if they have coronary disease, diabetes, prior stroke, or 10-year coronary event risk >10% 4
- Consider adding ezetimibe based on ASCVD risk and lipid levels 4
Monitoring Strategy
Monitor urinary albumin and eGFR 1-4 times per year depending on CKD stage. 1
- For patients with severely increased albuminuria (≥300 mg/g), target a 30% or greater reduction in urinary albumin to slow progression 1
- Assess risk factors regularly every 3-6 months 4
- All CKD patients should be considered at increased risk for acute kidney injury 2, 4
Additional Metabolic Targets
Consider treating metabolic acidosis when serum bicarbonate <18 mmol/L. 4
- Monitor to ensure bicarbonate doesn't exceed upper limit of normal or adversely affect BP, potassium, or fluid status 4
- Correcting metabolic acidosis may help slow progression 5
Nephrotoxin Avoidance
Avoid NSAIDs, proton-pump inhibitors, and iodinated contrast when possible. 5