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

Chronic Kidney Disease Management

Implement a comprehensive treatment strategy targeting blood pressure control, cardiovascular risk reduction, lifestyle modifications, and monitoring for metabolic complications to reduce CKD progression and improve mortality and quality of life outcomes. 1

Risk Stratification and Monitoring

• Use validated risk prediction equations incorporating eGFR and albuminuria to guide management intensity, with a 2-year kidney failure risk >10% triggering multidisciplinary care and >40% initiating kidney replacement therapy preparation 1
• For cardiovascular risk assessment, apply externally validated models developed specifically for CKD populations that incorporate both eGFR and albuminuria 1
• Monitor kidney function every 3-6 months in stable patients, with more frequent assessment in those at higher risk of progression 2

Blood Pressure Management

Target blood pressure <130/80 mmHg in patients with albuminuria ≥30 mg/24 hours and <140/90 mmHg in those without albuminuria. 2

• Initiate angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARBs) as first-line therapy, particularly in patients with albuminuria >300 mg/24 hours 2
• Titrate ACEi/ARBs to the maximum approved tolerated dose to maximize kidney protection 3
• Add dihydropyridine calcium channel blockers and/or diuretics as second-line agents to achieve blood pressure targets 2
• Monitor serum potassium and creatinine within 2-4 weeks after initiating or increasing ACEi/ARB doses 4

Common pitfall: Black patients may have reduced benefit from ARBs for left ventricular hypertrophy reduction, though blood pressure lowering effects remain 4

Cardiovascular Risk Reduction

Prescribe statin therapy for all adults ≥50 years with CKD regardless of GFR category. 3

• For adults 18-49 years with CKD, initiate statins if they have coronary disease, diabetes, prior stroke, or 10-year coronary event risk >10% 2
• Choose statin-based therapies that maximize absolute LDL-cholesterol reduction 3
• Add ezetimibe based on ASCVD risk and lipid levels 2
• Recommend a Mediterranean-style diet rich in plant-based foods in addition to lipid-lowering therapy 3

Lifestyle Modifications

Physical Activity

Advise patients to perform moderate-intensity physical activity for at least 150 minutes per week, adjusted to cardiovascular and physical tolerance. 1

• Explicitly counsel patients to avoid sedentary behavior 1
• For patients at high fall risk, provide specific guidance on exercise intensity (low, moderate, or vigorous) and type (aerobic versus resistance training) 1
• Children with CKD should aim for ≥60 minutes of daily physical activity per WHO guidelines 1

Weight Management

• Encourage weight loss in patients with obesity and CKD through diet, physical activity, and behavioral therapy 1
• Target achievement of optimal body mass index 1

Tobacco and Alcohol

• Strongly advise complete smoking cessation 1
• Limit alcohol consumption, as binge drinking accelerates CKD progression 5

Dietary Management

Advise adoption of healthy, diverse diets with higher consumption of plant-based foods compared to animal-based foods and lower consumption of ultraprocessed foods. 1

Protein Intake

• Maintain protein intake at 0.8 g/kg body weight/day in adults with CKD G3-G5 1
• Avoid high protein intake (>1.3 g/kg body weight/day) in adults at risk of CKD progression 1
• For highly motivated patients at high risk of kidney failure, consider a very low-protein diet (0.3-0.4 g/kg body weight/day) supplemented with essential amino acids or ketoacid analogs under close supervision 1
• Do not restrict protein in children with CKD due to risk of growth impairment; target protein intake at the upper end of normal range 1
• In older adults with frailty or sarcopenia, consider higher protein and calorie targets 1

Critical caveat: Do not prescribe low or very low-protein diets in metabolically unstable patients 1

Sodium Restriction

Limit sodium intake to <2 g per day (equivalent to <90 mmol/day or <5 g sodium chloride/day). 1

• This target helps control blood pressure and reduce proteinuria 2
• Refer patients to renal dietitians for education on sodium reduction strategies 1

Potassium Management

• Limit foods with high bioavailable potassium content (particularly processed foods) in patients with history of hyperkalemia 3
• Be aware that factors affecting potassium measurement include diurnal variation, sample type, and medication effects 2

Specialized Dietary Counseling

• Refer to renal dietitians or accredited nutrition providers for individualized education on sodium, phosphorus, potassium, and protein intake tailored to CKD severity and comorbidities 1

Glycemic Control in Diabetic CKD

• Target hemoglobin A1c of approximately 7% 2
• Use metformin as first-line therapy when eGFR ≥30 ml/min/1.73m² 2
• Add SGLT2 inhibitors when eGFR ≥20 ml/min/1.73m² and continue until dialysis or transplantation 2
• Consider GLP-1 receptor agonists when SGLT2 inhibitors and metformin are insufficient to meet glycemic targets 2
• Assess glycemic control twice yearly in stable patients meeting treatment goals, quarterly in those intensively managed or not meeting goals 1

Important consideration: HbA1c accuracy decreases in advanced CKD (stages G4-G5) and kidney failure 1

Management of Metabolic Complications

Metabolic Acidosis

• Provide pharmacological treatment with or without dietary intervention when serum bicarbonate <18 mmol/L 3
• Monitor treatment to ensure bicarbonate doesn't exceed normal limits or adversely affect blood pressure, potassium, or fluid balance 3

Hyperuricemia

• Treat symptomatic hyperuricemia (gout) with urate-lowering therapy, preferring xanthine oxidase inhibitors over uricosuric agents 3
• Do not prescribe urate-lowering therapy for asymptomatic hyperuricemia to delay CKD progression 3
• Recommend non-pharmacological measures including limiting alcohol, meat, and high-fructose corn syrup 3

Hyperkalemia

• Implement dietary and pharmacologic interventions for patients with CKD G3-G5 and hyperkalemia 2
• Consider potassium binders when dietary restriction and medication adjustments are insufficient 2

Anemia, CKD-MBD, and Other Laboratory Abnormalities

• Monitor and treat anemia, CKD-mineral and bone disorders, potassium disorders, and acidosis as they have direct implications for health outcomes 1

Medication Management

• Adjust all medication dosages according to kidney function 3
• Avoid nephrotoxins, particularly nonsteroidal anti-inflammatory drugs 6
• For atrial fibrillation, prefer non-vitamin K antagonist oral anticoagulants (NOACs) over vitamin K antagonists, with appropriate dose adjustments based on GFR 3

Critical warning with ACEi/ARBs: Monitor for worsening kidney function, hyperkalemia, and hypotension; patients may experience dizziness, particularly when initiating therapy 4

Multidisciplinary Care and Referrals

• Refer to nephrology when 5-year kidney failure risk is 3-5% or when eGFR <30 ml/min/1.73m² or albuminuria ≥300 mg per 24 hours 7, 6
• Refer to renal dietitians for specialized nutritional counseling 1, 2
• Consider referrals to psychologists, pharmacists, physical/occupational therapy, and smoking cessation programs as indicated 1

Symptom Management and Quality of Life

• Regularly screen for symptoms using validated tools 2
• Screen for and treat depression, which affects approximately 26.5% of patients with CKD stages 1-4 2
• Address pain using a stepwise approach starting with non-pharmacological interventions 2
• Maximize health-related quality of life, physical function, capacity to work, and ability to socialize 1