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

Management of Chronic Kidney Disease

Implement a comprehensive treatment strategy targeting blood pressure control with ACEi/ARBs, cardiovascular risk reduction with statins, lifestyle modifications including 150 minutes weekly of moderate exercise, dietary sodium restriction to <2g/day, and protein intake of 0.8g/kg/day, while monitoring for metabolic complications to reduce CKD progression and improve mortality outcomes. 1

Risk Stratification and Monitoring Framework

• Use validated risk prediction equations incorporating eGFR and albuminuria to determine management intensity 1
• Trigger multidisciplinary care when 2-year kidney failure risk exceeds 10% 1, 2
• Initiate kidney replacement therapy preparation when 2-year risk exceeds 40% 1, 2
• Monitor kidney function every 3-6 months based on individual risk, recognizing that small GFR fluctuations are common and don't necessarily indicate progression 2, 3
• Consider all CKD patients at increased risk for acute kidney injury 2, 3

Blood Pressure Management Algorithm

For patients WITH albuminuria ≥30 mg/24h: Target BP <130/80 mmHg 1, 2, 3

For patients WITHOUT albuminuria (<30 mg/24h): Target BP <140/90 mmHg 1, 2, 3

Pharmacologic Approach:

• Start with ACEi or ARBs as first-line therapy, particularly when albuminuria exceeds 300 mg/24h 1, 2, 3
• Add dihydropyridine calcium channel blockers and/or diuretics to achieve BP targets 2, 3
• Check for postural hypotension regularly when treating with BP-lowering drugs 2

Common pitfall: Dual ACEi/ARB combination therapy has shown surprising negative results in recent trials and should be avoided 4

Cardiovascular Risk Reduction Protocol

Statin Therapy:

• Prescribe statins for ALL adults ≥50 years with CKD regardless of GFR category 1, 2, 3
• For adults 18-49 years, initiate statins if they have coronary disease, diabetes, prior stroke, or 10-year coronary event risk >10% 1, 2, 3
• Add ezetimibe based on ASCVD risk and lipid levels 2, 3

Antiplatelet Therapy:

• Consider antiplatelet therapy for patients with established cardiovascular disease 2, 3

Anticoagulation:

• Prefer non-vitamin K antagonist oral anticoagulants (NOACs) over vitamin K antagonists, with appropriate dose adjustments based on GFR 1, 2

Lifestyle Modifications

Physical Activity:

• Prescribe moderate-intensity physical activity for at least 150 minutes per week, adjusted to cardiovascular and physical tolerance 1, 2, 3
• Advise patients to avoid sedentary behavior 2, 3
• Provide specific advice on exercise intensity and type for patients at higher risk of falls 2, 3

Weight Management:

• Encourage weight loss in patients with obesity through diet, physical activity, and behavioral therapy 1, 2, 3

Smoking Cessation:

• Promote smoking cessation as tobacco use accelerates CKD progression 2, 3

Dietary Management Protocol

Protein Intake:

• Maintain protein intake at 0.8 g/kg body weight/day in adults with CKD G3-G5 1, 2, 3
• Avoid high protein intake (>1.3 g/kg/day) in adults at risk of progression 2, 3

Critical exception: Do NOT restrict protein in children with CKD due to risk of growth impairment 2

Sodium Restriction:

• Limit sodium intake to <2 g per day (equivalent to <90 mmol/day or <5 g sodium chloride/day) 1, 2, 3

Dietary Pattern:

• Adopt healthy, diverse diets with higher consumption of plant-based foods compared to animal-based foods and lower consumption of ultraprocessed foods 1, 2, 3

Potassium Management:

• Limit foods with high potassium content in patients with history of hyperkalemia 2, 3
• Be aware of factors affecting potassium measurement including diurnal variation, sample type, and medication effects 2, 3

Glycemic Control in Diabetic CKD

• Target hemoglobin A1c of approximately 7% 1, 2, 3

Medication Algorithm:

1. First-line: Use metformin when eGFR ≥30 ml/min/1.73m² 1, 2, 3
2. Second-line: Add SGLT2 inhibitors when eGFR ≥20 ml/min/1.73m² and continue until dialysis or transplantation 2, 3
3. Third-line: Consider GLP-1 receptor agonists when SGLT2 inhibitors and metformin are insufficient 3

Important note: SGLT2 inhibitors have shown to slow GFR decline and provide additional benefits in weight reduction and cardiovascular outcomes 5

Management of Metabolic Complications

Metabolic Acidosis:

• Provide pharmacological treatment with or without dietary intervention when serum bicarbonate <18 mmol/L 1, 2, 3
• Monitor treatment to ensure serum bicarbonate doesn't exceed normal limits and doesn't negatively impact blood pressure, serum potassium, or fluid balance 2, 3

Hyperkalemia:

• Implement an individualized approach including dietary and pharmacologic interventions for patients with CKD G3-G5 and hyperkalemia 2, 3
• New potassium-lowering therapies have shown improved tolerance, allowing higher dosage of renin-angiotensin system inhibitors 5

Hyperuricemia:

• Treat symptomatic hyperuricemia (gout) with urate-lowering therapy, preferring xanthine oxidase inhibitors over uricosuric agents 1

Medication Management

• Adjust ALL medication dosages according to kidney function 1, 2, 6
• Avoid potential nephrotoxins, particularly nonsteroidal anti-inflammatory drugs 6, 5
• Implement deprescribing protocols to reduce pill burden and avoid potentially inappropriate medications 2

Symptom Management and Quality of Life

• Regularly screen for symptoms using validated tools 1, 2, 3
• Screen for and treat depression, which affects approximately 26.5% of patients with CKD stages 1-4 1, 2, 3
• Address pain using a stepwise approach, starting with non-pharmacological interventions and advancing to pharmacological therapy as needed 2, 3
• Maximize health-related quality of life, physical function, capacity to work, and ability to socialize 1

Nephrology Referral Criteria

• Refer when 5-year kidney failure risk is 3-5% 1
• Refer when eGFR <30 ml/min/1.73m² 1, 6
• Refer when albuminuria ≥300 mg per 24 hours 1, 6
• Refer for rapid decline in estimated GFR 6

Multidisciplinary Care

• Refer to renal dietitians for specialized nutritional counseling 1, 2, 3
• Consider referral to psychologists, pharmacists, and physical therapy as indicated 3

Special Pediatric Considerations

• Encourage physical activity aiming for ≥60 minutes daily and achievement of healthy weight 2, 3
• Do NOT restrict protein intake in children with CKD due to risk of growth impairment 2