What is the recommended treatment approach for a patient with Chronic Kidney Disease (CKD)?

Comprehensive Treatment Approach for Chronic Kidney Disease

All adults ≥50 years with CKD and eGFR <60 mL/min/1.73 m² should be treated with a statin or statin/ezetimibe combination to reduce cardiovascular mortality, which is the leading cause of death in CKD patients. 1

Cardiovascular Risk Reduction (Primary Priority)

Statin Therapy - Mandatory for Most Patients

Age ≥50 years with eGFR <60 mL/min/1.73 m² (CKD G3a-G5):

• Start statin or statin/ezetimibe combination immediately (Grade 1A recommendation) 1
• For severe renal impairment, start rosuvastatin 5 mg daily, maximum 10 mg daily 2
• Choose regimens that maximize absolute LDL cholesterol reduction for greatest mortality benefit 1

Age ≥50 years with eGFR ≥60 mL/min/1.73 m² (CKD G1-G2):

• Statin monotherapy recommended (Grade 1B) 1

Age 18-49 years:

• Initiate statin if ANY of the following present (Grade 2A): 1
  • Known coronary disease (MI or revascularization)
  • Diabetes mellitus
  • Prior ischemic stroke
  • 10-year cardiovascular risk >10% (calculate using validated risk tool)
• Consider statin even with <10% 10-year risk in this age group 1

Additional lipid management:

• Consider PCSK-9 inhibitors when indicated 1
• Implement plant-based Mediterranean-style diet alongside pharmacotherapy 1

Blood Pressure Management with Renal Protection

Renin-Angiotensin System Inhibitors:

• Use ACE inhibitors or ARBs (such as losartan) for blood pressure control and nephroprotection 3, 4, 5
• Losartan specifically indicated for diabetic nephropathy with elevated creatinine and proteinuria (albumin:creatinine ratio ≥300 mg/g) in type 2 diabetes with hypertension 3
• Reduces progression to doubling of serum creatinine or end-stage renal disease 3

Critical monitoring requirements:

• Monitor renal function periodically; consider withholding if clinically significant decline occurs 3
• Monitor serum potassium regularly due to hyperkalemia risk 3
• Correct volume or salt depletion before initiating therapy to prevent symptomatic hypotension 3
• Patients with renal artery stenosis, severe CHF, or volume depletion are at particular risk for acute renal failure 3

Antiplatelet Therapy for Secondary Prevention

Low-dose aspirin:

• Recommend for secondary prevention in CKD patients with established ischemic cardiovascular disease (Grade 1C) 1
• Use P2Y12 inhibitors if aspirin intolerance exists 1

Management of Stable Coronary Artery Disease

Conservative approach preferred:

• In stable stress-test confirmed ischemic heart disease, intensive medical therapy is appropriate alternative to invasive strategy (Grade 2D) 1
• Invasive strategy still preferable for: acute/unstable coronary disease, unacceptable angina, LV systolic dysfunction from ischemia, or left main disease 1

Atrial Fibrillation Management

Anticoagulation:

• Use NOACs (non-vitamin K antagonist oral anticoagulants) over warfarin for CKD G1-G4 (Grade 1C) 1
• NOAC dose adjustment required based on GFR, with particular caution at CKD G4-G5 1
• Screen opportunistically with pulse checks during BP measurement, followed by wearable device or Holter ECG if indicated 1

Rate/rhythm control:

• Use beta-blockers to control ventricular rate to <90 bpm at rest 1
• Consider cardioversion, antiarrhythmic therapy, or catheter ablation if symptoms persist despite adequate rate control 1

Management of Inflammatory Conditions in CKD

Critical medication avoidance:

• Never prescribe NSAIDs in CKD due to nephrotoxicity and acute kidney injury risk 1, 6, 5
• For acute gout or inflammatory conditions, use low-dose colchicine or oral/intra-articular glucocorticoids instead 1, 6

Hyperuricemia:

• Do NOT use uric acid-lowering agents for asymptomatic hyperuricemia to delay CKD progression (Grade 2D) 1
• Limit alcohol, meats, and high-fructose corn syrup intake to prevent gout 1, 6

Monitoring for CKD Complications

Regular surveillance required for: 5, 7

• Hyperkalemia (especially with RAS inhibitors)
• Metabolic acidosis
• Hyperphosphatemia
• Vitamin D deficiency and secondary hyperparathyroidism
• Anemia
• Volume status

Nephrology Referral Criteria

Prompt referral indicated for: 5

• eGFR <30 mL/min/1.73 m²
• Albuminuria ≥300 mg per 24 hours
• Rapid decline in eGFR
• Difficulty managing complications

Critical Pitfalls to Avoid

• Never use NSAIDs in CKD patients, even short-term - significantly increases acute kidney injury and progression risk 1, 6, 5
• Do not overlook statin therapy - cardiovascular disease is the leading cause of mortality in CKD, not kidney failure itself 6, 2
• Avoid nephrotoxic medications and adjust drug dosing for many antibiotics and oral hypoglycemics 5
• Do not discontinue RAS inhibitors for minor creatinine elevations - monitor but maintain therapy unless clinically significant decline 3, 4
• Discontinue RAS inhibitors immediately if pregnancy detected - causes fetal toxicity, oligohydramnios, and neonatal death 3