What are the initial treatment approaches for chronic kidney disease (CKD)?

Initial Treatment Approaches for Chronic Kidney Disease

All patients with CKD should receive a comprehensive treatment strategy built on a foundation of lifestyle modifications, blood pressure control with RAS inhibition (when albuminuria is present), SGLT2 inhibitors, and statin therapy, with regular reassessment every 3-6 months to reduce risks of kidney disease progression and cardiovascular disease. 1

Foundation: Lifestyle Modifications

These interventions form the cornerstone of CKD management and should be implemented immediately for all patients:

• Smoking cessation is mandatory, as tobacco use accelerates CKD progression 1, 2
• Physical activity: Engage in moderate-intensity exercise for at least 150 minutes per week to improve cardiovascular health and slow CKD progression 2, 3
• Dietary approach: Adopt a plant-based "Mediterranean-style" diet to reduce cardiovascular risk 1, 2
• Weight management: Achieve optimal body mass index through structured weight loss programs 2, 4
• Alcohol limitation: Avoid binge drinking, which increases CKD progression risk 4
• Referral to specialists: Consider renal dietitians, physical therapists, and smoking cessation programs when appropriate 2

First-Line Pharmacotherapy

Blood Pressure Control

• Target: Aim for systolic blood pressure <120 mmHg based on the most recent evidence 2
• First-line agent: Initiate RAS inhibition (ACE inhibitor or ARB) at maximum tolerated dose, particularly when albuminuria is present 1, 2
• Alternative targets: For patients without albuminuria, BP <140/90 mmHg is acceptable; with albuminuria, target <130/80 mmHg 4
• Additional agents: Add dihydropyridine calcium channel blockers and/or diuretics if needed to achieve targets 2
• Monitoring: Use 24-hour ambulatory BP devices for accurate assessment 2

Critical pitfall: Do not discontinue RAS inhibitors prematurely if creatinine increases up to 30% from baseline—this is acceptable and expected 2

SGLT2 Inhibitors

• Initiate SGLT2 inhibitors as first-line therapy for most patients with CKD grades 1-2, regardless of diabetes status 2
• Start when eGFR ≥20 ml/min per 1.73 m² and continue until dialysis initiation 1
• For type 2 diabetes patients, combine with metformin when eGFR ≥30 ml/min per 1.73 m² 1
• Do not delay initiation—these agents have proven significant benefits in slowing CKD progression 2

Lipid Management

For patients aged ≥50 years:

• Initiate statin therapy for all patients with CKD grades G1-G2 (eGFR ≥60 ml/min per 1.73 m²) 1
• For eGFR <60 ml/min per 1.73 m² (G3a-G5), use statin or statin/ezetimibe combination 1

For patients aged 18-49 years:

• Suggest statin therapy if they have known coronary disease, diabetes mellitus, prior ischemic stroke, or estimated 10-year cardiovascular risk >10% 1
• Consider lower thresholds (<10% 10-year risk) for statin initiation 1
• Maximize LDL cholesterol reduction to achieve largest treatment benefits 1

Additional Cardiovascular Protection

• GLP-1 receptor agonists: For type 2 diabetes patients when SGLT2 inhibitors/metformin are insufficient or not tolerated 1, 2
• Nonsteroidal mineralocorticoid receptor antagonists: Consider for type 2 diabetes patients with persistent albuminuria >30 mg/g despite first-line therapy 1, 2
• Low-dose aspirin: Recommend for secondary prevention in patients with established ischemic cardiovascular disease 1, 2
• Consider P2Y12 inhibitors when aspirin is not tolerated 1

Glycemic Control (for Diabetic CKD)

• First-line: Metformin (when eGFR ≥30 ml/min per 1.73 m²) combined with SGLT2 inhibitors 1
• Second-line: Add GLP-1 receptor agonists if glycemic targets are not met 1
• Optimize glycemic control to slow progression, as hyperglycemia accelerates diabetic CKD 4

Medication Safety

• Review all medications for appropriate dosing based on kidney function 2, 5
• Avoid nephrotoxins, particularly NSAIDs, which worsen kidney function 1, 2, 5
• Monitor drug interactions and adjust doses for antibiotics, gabapentinoids, and oral hypoglycemic agents 1, 5
• Minimize IV contrast exposure when possible 1

Monitoring Schedule

• Reassess risk factors every 3-6 months 1, 2
• Monitor serum creatinine, potassium, and albuminuria regularly 2
• Screen for CKD complications: hyperkalemia, metabolic acidosis, hyperphosphatemia, vitamin D deficiency, secondary hyperparathyroidism, and anemia 5
• Use validated risk tools to estimate 10-year cardiovascular risk 1

Patient Education and Engagement

• Provide interactive, frequent, multifaceted educational interventions to improve knowledge and self-management 1
• Ensure materials are culturally appropriate and at appropriate literacy levels 1
• Facilitate access to multidisciplinary teams including dietitians and diabetes educators 1
• Utilize patient portals for direct provider access and medical information 1

Common Pitfalls to Avoid

• Do not delay SGLT2 inhibitor initiation—benefits are substantial and time-sensitive 2
• Do not stop RAS inhibitors for creatinine increases up to 30% 2
• Do not ignore modifiable risk factors such as smoking, obesity, and sedentary lifestyle 2
• Do not fail to address albuminuria—it impacts choice of antihypertensive agents 1
• Do not initiate statins in patients starting dialysis, though continuation is acceptable if already prescribed 1