What is the full treatment for Chronic Kidney Disease (CKD) including brand names of drugs?

Comprehensive Treatment of Chronic Kidney Disease with Brand Names

All CKD patients should receive SGLT2 inhibitors as foundational first-line therapy combined with RAS inhibition (ACE inhibitor or ARB) when hypertension or albuminuria is present, plus statin therapy, forming the core triad of kidney and cardiovascular protection. 1

First-Line Pharmacological Therapy

SGLT2 Inhibitors (Mandatory for Most Patients)

• Initiate immediately when eGFR ≥20 mL/min/1.73 m² and continue until dialysis or transplantation 1, 2
• Brand name options:
  • Jardiance (empagliflozin) - most widely studied in CKD
  • Farxiga (dapagliflozin) - FDA approved for CKD with and without diabetes
  • Invokana (canagliflozin) - proven kidney protection
• Continue SGLT2 inhibitors even as eGFR declines below 20 mL/min/1.73 m² until dialysis initiation 1

RAS Inhibition (ACE Inhibitors or ARBs)

• Mandatory when albuminuria is present; first-line when hypertension exists 1
• Titrate to maximum tolerated dose for optimal kidney and cardiovascular protection 1, 3, 4
• ACE Inhibitor brand options:
  • Vasotec (enalapril)
  • Prinivil/Zestril (lisinopril)
  • Altace (ramipril)
• ARB brand options (if ACE inhibitor not tolerated):
  • Cozaar (losartan)
  • Diovan (valsartan)
  • Atacand (candesartan)

Statin Therapy (Universal Recommendation)

• All adults ≥50 years with eGFR <60 mL/min/1.73 m² require statin or statin/ezetimibe combination 1, 2
• All adults ≥50 years with eGFR ≥60 mL/min/1.73 m² require statin therapy 1
• High-intensity statin brand options:
  • Lipitor (atorvastatin) 40-80 mg daily
  • Crestor (rosuvastatin) 20-40 mg daily
• Add Zetia (ezetimibe) 10 mg daily if LDL targets not met or high ASCVD risk 1

Blood Pressure Management

Target and Strategy

• Target systolic BP <120 mmHg for most CKD patients to reduce progression risk 1, 3, 4
• When albuminuria present: ACE inhibitor or ARB must be first-line agent 1, 4

Additional Antihypertensive Agents (When Needed)

• Dihydropyridine calcium channel blockers:
  • Norvasc (amlodipine) 5-10 mg daily
  • Procardia XL (nifedipine extended-release) 30-90 mg daily 1
• Diuretics (often required for volume management):
  • Lasix (furosemide) - for eGFR <30 mL/min/1.73 m²
  • Bumex (bumetanide) - alternative loop diuretic
  • Hydrochlorothiazide - only effective when eGFR >30 mL/min/1.73 m² 1

Advanced Kidney and Heart Protection

Nonsteroidal Mineralocorticoid Receptor Antagonist

• Kerendia (finerenone) 10-20 mg daily for Type 2 diabetes patients with persistent albuminuria ≥30 mg/g despite RAS inhibition and normal potassium 1, 5, 6
• Provides additive kidney and cardiovascular protection beyond SGLT2 inhibitors and RAS blockade 1, 6
• Monitor potassium closely; combination with SGLT2 inhibitor reduces hyperkalemia risk 6

Steroidal MRA (For Resistant Hypertension Only)

• Aldactone (spironolactone) 12.5-25 mg daily - use only when BP uncontrolled despite multiple agents 1
• Requires strict potassium monitoring (risk of hyperkalemia) 1

Diabetes Management in CKD

Glycemic Control Strategy

• Metformin (Glucophage) 500-1000 mg twice daily when eGFR ≥30 mL/min/1.73 m²; discontinue if eGFR <30 1, 3
• SGLT2 inhibitors serve dual purpose: glycemic control AND kidney protection 1

GLP-1 Receptor Agonists (Additional Therapy)

• Add when SGLT2 inhibitor and metformin insufficient for glycemic targets or if SGLT2i/metformin contraindicated 1, 2
• Brand options with cardiovascular benefits:
  • Ozempic (semaglutide) 0.5-1 mg weekly subcutaneous
  • Victoza (liraglutide) 1.2-1.8 mg daily subcutaneous
  • Trulicity (dulaglipine) 1.5 mg weekly subcutaneous 1

Insulin Therapy

• Required for Type 1 diabetes; may be needed for Type 2 diabetes as kidney function declines 1
• Adjust doses carefully as insulin clearance decreases with declining eGFR 7

Lipid Management Beyond Statins

Additional Lipid-Lowering Agents

• Repatha (evolocumab) or Praluent (alirocumab) - PCSK9 inhibitors for high ASCVD risk patients not at LDL goal despite statin/ezetimibe 1
• Vascepa (icosapent ethyl) 2 grams twice daily for patients with elevated triglycerides and high ASCVD risk 1

Management of CKD Complications

Anemia Management

• Monitor hemoglobin regularly; treat when below target levels 2, 8
• Iron supplementation BEFORE or with erythropoiesis-stimulating agents:
  • Oral: Feosol (ferrous sulfate) 325 mg daily to three times daily
  • IV: Venofer (iron sucrose) or Injectafer (ferric carboxymaltose) 2, 8
• Erythropoiesis-stimulating agents (ESAs):
  • Procrit/Epogen (epoetin alfa) 50-100 Units/kg three times weekly IV/SC
  • Aranesp (darbepoetin alfa) - longer-acting alternative
  • Target hemoglobin ≤11 g/dL (higher targets increase cardiovascular risk and mortality) 8
  • Use lowest dose to avoid transfusions 8

Metabolic Acidosis

• Treat when serum bicarbonate persistently low to maintain normal range 2, 3
• Sodium bicarbonate 650 mg (1-2 tablets) two to three times daily 2, 3

Hyperkalemia Management

• Monitor potassium closely, especially with RAS inhibitors, MRAs, or NSAIDs 1, 2
• Dietary potassium restriction focusing on processed foods high in bioavailable potassium 1
• Potassium binders for persistent hyperkalemia:
  • Veltassa (patiromer) 8.4-25.2 grams daily
  • Lokelma (sodium zirconium cyclosilicate) 10 grams three times daily initially, then 10 grams daily 1

Mineral Bone Disease

• Phosphate binders when hyperphosphatemia develops (typically eGFR <30):
  • Renvela/Renagel (sevelamer) 800-1600 mg three times daily with meals
  • PhosLo (calcium acetate) 667-1334 mg three times daily with meals
  • Velphoro (sucroferric oxyhydroxide) 500 mg three times daily with meals 7
• Vitamin D supplementation:
  • Ergocalciferol (vitamin D2) or cholecalciferol (vitamin D3) for deficiency
  • Active vitamin D analogs (calcitriol, paricalcitol) for secondary hyperparathyroidism in advanced CKD 7

Hyperuricemia and Gout

• Treat symptomatic hyperuricemia (gout) with uric acid-lowering therapy 1
• Zyloprim (allopurinol) 100-300 mg daily - xanthine oxidase inhibitor preferred over uricosuric agents 1
• Uloric (febuxostat) 40-80 mg daily - alternative xanthine oxidase inhibitor 1
• For acute gout: low-dose Colcrys (colchicine) 0.6 mg once or twice daily OR oral/intra-articular glucocorticoids 1, 4
• NEVER use NSAIDs in CKD patients due to nephrotoxicity and acute kidney injury risk 1, 4, 7

Cardiovascular Disease Management

Antiplatelet Therapy

• Aspirin 81 mg daily for secondary prevention in established cardiovascular disease (lifelong) 1, 4
• Consider for primary prevention in high ASCVD risk patients 1

Anticoagulation for Atrial Fibrillation

• NOACs preferred over warfarin in CKD G1-G4:
  • Eliquis (apixaban) 5 mg twice daily (2.5 mg twice daily if dose reduction criteria met)
  • Xarelto (rivaroxaban) 20 mg daily with evening meal (15 mg if CrCl 15-50)
  • Pradaxa (dabigatran) - avoid if eGFR <30 mL/min/1.73 m² 4

Lifestyle Modifications (Foundation of All Therapy)

Dietary Interventions

• Protein intake: exactly 0.8 g/kg body weight/day for CKD G3-G5 (avoid >1.3 g/kg/day which accelerates progression) 2, 3, 4
• Sodium restriction: <2,300 mg/day (<100 mmol/day) 2, 3, 4
• Mediterranean-style, plant-based diet with higher plant-based foods versus animal-based foods 3, 4
• Limit ultraprocessed foods 4
• Potassium restriction individualized based on serum levels 1, 2

Physical Activity

• 150 minutes weekly of moderate-intensity exercise or to level compatible with cardiovascular tolerance 2, 3, 4

Other Lifestyle Factors

• Smoking cessation mandatory 1
• Weight management targeting healthy BMI 1, 2
• Limit alcohol intake 1

Monitoring Schedule

Regular Reassessment

• Every 3-6 months: eGFR, electrolytes (sodium, potassium, bicarbonate), urine albumin-to-creatinine ratio, hemoglobin, blood pressure 1, 2, 3, 4
• More frequent monitoring after medication changes affecting RAS or potassium 3
• 10-year cardiovascular risk assessment using validated tool 1

Nephrology Referral Criteria

Immediate Referral Indicated When:

• eGFR <30 mL/min/1.73 m² (CKD G4-G5) 2, 3, 7
• Albuminuria ≥300 mg/24 hours (ACR ≥300 mg/g) 3, 7
• Rapid decline in eGFR (>5 mL/min/1.73 m² per year) 3, 7
• Difficult-to-control hypertension despite multiple agents 7
• Persistent electrolyte abnormalities 7
• Uncertain CKD etiology 7

Critical Medications to AVOID in CKD

Absolute Contraindications

• NSAIDs (ibuprofen/Advil, naproxen/Aleve, ketorolac/Toradol) - cause acute kidney injury and accelerate progression 1, 4, 7
• Avoid proton pump inhibitors unless absolutely necessary (associated with interstitial nephritis) 3
• Limit herbal/dietary supplements (many nephrotoxic or interact with medications) 3

Medications Requiring Dose Adjustment

• All renally-cleared medications require eGFR-based dose adjustment 3, 7
• Many antibiotics (especially aminoglycosides, vancomycin) 7
• Oral hypoglycemic agents (especially sulfonylureas, DPP-4 inhibitors) 7
• Use extreme caution with iodinated contrast and gadolinium-based agents 3

Common Pitfalls to Avoid

• Delaying SGLT2 inhibitor initiation - should be started immediately upon CKD diagnosis regardless of diabetes status 2, 4, 9
• Undertitrating RAS inhibitors - must push to maximum tolerated dose for optimal protection 1, 3, 4
• Stopping SGLT2 inhibitors when eGFR declines - continue until dialysis 1
• Targeting hemoglobin >11 g/dL with ESAs - increases mortality and cardiovascular events 8
• Failing to add finerenone in diabetic patients with persistent albuminuria - provides additive protection 1, 6
• Late nephrology referral (waiting until eGFR <15) - refer at eGFR <30 for optimal outcomes 2, 3, 7
• Overlooking lifestyle modifications while focusing only on medications 2, 4