Chronic Kidney Disease (CKD) Management
Core Treatment Framework
All CKD patients require a comprehensive treatment strategy layered on lifestyle optimization, with evidence-based pharmacologic therapies aimed at preserving kidney function, reducing cardiovascular risk, and managing metabolic complications. 1
Risk Stratification and Monitoring Frequency
Use validated risk prediction equations incorporating both eGFR and albuminuria to determine monitoring intensity and trigger interventions. 2
- Monitor patients 1-4 times per year based on CKD stage and albuminuria level 3
- Refer to nephrology when:
- Initiate kidney replacement therapy preparation when 2-year kidney failure risk >40% 2
First-Line Pharmacologic Therapies
SGLT2 Inhibitors (Diabetic and Non-Diabetic CKD)
Initiate SGLT2 inhibitors when eGFR ≥20 ml/min/1.73m² and continue until dialysis or transplant. 1, 3 This represents a paradigm shift as these agents provide kidney and cardiovascular protection independent of glucose-lowering effects.
RAS Inhibition
Start ACE inhibitors or ARBs at maximum tolerated dose in all patients with:
These agents reduce proteinuria and consistently slow progression in both diabetic and non-diabetic nephropathy. 4
Metformin
Use metformin as first-line glucose-lowering therapy when eGFR ≥30 ml/min/1.73m². 1, 3
Statins
Prescribe moderate- or high-intensity statins to:
- All adults ≥50 years with CKD regardless of GFR 2, 3
- Adults 18-49 years with coronary disease, diabetes, prior stroke, or 10-year coronary event risk >10% 2, 3
Blood Pressure Targets
Target BP <130/80 mmHg in patients with albuminuria ≥30 mg/24 hours. 2, 3
Target BP <140/90 mmHg in patients without albuminuria. 2, 3
- Use RAS inhibitors as first-line 1
- Add dihydropyridine calcium channel blockers and/or diuretics as needed to achieve target 1
- Consider nonsteroidal mineralocorticoid receptor antagonists (MRAs) if albuminuria ≥30 mg/g and normal potassium 1
Glycemic Control (Diabetic CKD)
Target HbA1c approximately 7%. 2, 3
Medication hierarchy:
- Metformin when eGFR ≥30 ml/min/1.73m² 1, 3
- SGLT2 inhibitor when eGFR ≥20 ml/min/1.73m² 1, 3
- GLP-1 receptor agonist if needed to achieve glycemic target 1
- Other glucose-lowering drugs as needed 1
Assess HbA1c twice yearly in stable patients meeting goals, quarterly in those intensively managed or with therapy changes. 1
Lifestyle Modifications
Physical Activity
Prescribe moderate-intensity physical activity for cumulative duration of at least 150 minutes per week. 1, 2 Adjust intensity based on cardiovascular tolerance, frailty risk, and fall risk. 1
Advise patients to avoid sedentary behavior. 1
Weight Management
Encourage weight loss in overweight or obese patients through diet, physical activity, and behavioral therapy. 1, 2
Smoking Cessation
Strongly advise complete smoking cessation. 1 Smoking accelerates CKD progression. 5
Dietary Management
Overall Dietary Pattern
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, 2 A Mediterranean-style diet reduces cardiovascular risk. 4, 3
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 body weight/day. 1 Higher protein intakes may enhance kidney function decline. 1
Sodium Restriction
Limit sodium intake to <2 g per day (equivalent to <90 mmol/day or <5 g sodium chloride/day). 2, 3 This controls blood pressure and reduces proteinuria. 3
Specialized Nutritional Counseling
Refer to renal dietitians or accredited nutrition providers for individualized education about dietary adaptations. 1, 2 This is particularly important for managing sodium, phosphorus, potassium, and protein intake tailored to CKD severity and comorbidities. 1
Additional Risk-Based Therapies
Nonsteroidal Mineralocorticoid Receptor Antagonists
Consider nonsteroidal MRA (finerenone) if albuminuria ≥30 mg/g and normal potassium. 1 These agents have proven clinical kidney and cardiovascular benefits. 1
Advanced Lipid Management
Add ezetimibe, PCSK9 inhibitors, or icosapent ethyl if indicated based on ASCVD risk and lipid levels. 1
Antiplatelet Therapy
Prescribe antiplatelet agents for clinical atherosclerotic cardiovascular disease. 1
Management of Metabolic Complications
Metabolic Acidosis
Provide pharmacological treatment with or without dietary intervention when serum bicarbonate <18 mmol/L. 2, 3 Monitor to ensure bicarbonate doesn't exceed upper limit of normal or adversely affect BP, potassium, or fluid status. 3
Hyperuricemia
Treat symptomatic hyperuricemia (gout) with urate-lowering therapy, preferring xanthine oxidase inhibitors over uricosuric agents. 2
Anemia and Mineral-Bone Disorders
Monitor and treat laboratory abnormalities including anemia and CKD-mineral and bone disorders. 1 These have direct implications for health outcomes.
Medication Safety
Adjust all medication dosages according to kidney function. 2
Avoid nephrotoxins, particularly nonsteroidal anti-inflammatory drugs. 6
Prefer non-vitamin K antagonist oral anticoagulants (NOACs) over vitamin K antagonists, with appropriate dose adjustments based on GFR. 2
Multidisciplinary Care Model
Implement a team-based integrated approach including diabetes care and education specialists, physicians, nurse practitioners, physician assistants, nurses, dietitians, exercise specialists, pharmacists, and mental health professionals. 1 This represents a key strategy to overcome barriers to effective CKD management. 1
Regularly screen for depression using validated tools, as it affects approximately 26.5% of patients with CKD stages 1-4. 2
Quality of Life and Symptom Management
Regularly screen for symptoms using validated tools and maximize health-related quality of life, physical function, capacity to work, and ability to socialize. 2
The ultimate goal is reducing morbidity and mortality while preserving quality of life, not just laboratory targets. 1
Critical Pitfalls to Avoid
Therapeutic inertia is a major barrier. 1 Most patients with CKD have high residual risks of progression and cardiovascular disease despite treatment. 1 Avoid delaying intensification of therapy when targets are not met.
All CKD patients should be considered at increased risk of acute kidney injury, which can accelerate CKD progression. 4 Vigilance during acute illnesses and medication changes is essential.
Reassess risk factors every 3-6 months including glycemia, albuminuria, BP, cardiovascular risk, and lipids. 1 This frequent reassessment prevents missed opportunities for intervention.