Management Strategies for Chronic Kidney Disease
First-Line Pharmacologic Therapy
SGLT2 inhibitors should be initiated in most CKD patients as first-line therapy and continued until dialysis or transplant, representing the most significant advancement in CKD management with robust evidence for delaying progression and reducing cardiovascular complications. 1, 2
Core Medication Regimen
SGLT2 inhibitors are recommended as first-line therapy for most CKD patients, regardless of diabetes status, and should be continued until dialysis or transplantation 1, 2, 3
RAS inhibition (ACE inhibitor or ARB) must be prescribed at maximum tolerated dose when albuminuria is present, and is first-line when hypertension exists 1, 2
- For nondiabetic adults with albuminuria ≥300 mg/24h, ACE inhibitor or ARB is strongly recommended 1
- For nondiabetic adults with albuminuria 30-300 mg/24h, ACE inhibitor or ARB is suggested 1
- Titrate to the highest approved dose that is tolerated to maximize kidney protection 2
- Do not discontinue due to modest increases in serum creatinine or potassium unless specific contraindications exist 2
Statin-based lipid therapy (moderate to high-intensity) is mandatory for all adults ≥50 years with eGFR <60 mL/min/1.73 m² (CKD G3a-G5) 1, 2, 3
- For adults aged 18-49 years, prescribe statins if they have coronary disease, diabetes, prior stroke, or 10-year coronary event risk >10% 1, 4
- Choose regimens that maximize absolute LDL cholesterol reduction 1, 2
- Consider adding ezetimibe based on ASCVD risk and lipid levels 4
- Consider PCSK-9 inhibitors for patients with CKD who have an indication for their use 1
Nonsteroidal mineralocorticoid receptor antagonists (ns-MRA) should be used in people with diabetes 1
Blood Pressure Management
Target systolic blood pressure <120 mmHg for most CKD patients, representing a more aggressive target than previous guidelines and supported by cardiovascular outcome data. 1, 2
Blood Pressure Targets by Albuminuria Status
For patients without albuminuria (<30 mg/24h): target BP ≤140/90 mmHg 1, 2, 3
For patients with albuminuria 30-300 mg/24h: target BP ≤130/80 mmHg 1, 2, 3
For patients with albuminuria ≥300 mg/24h: target BP ≤130/80 mmHg 1, 2, 3
Antihypertensive Medication Strategy
When albuminuria is present, ACE inhibitor or ARB must be first-line antihypertensive therapy given proven kidney protective effects 1, 2, 4
Add dihydropyridine calcium channel blocker and/or diuretic as needed to achieve individualized BP targets 1, 4
Inquire about postural dizziness and check for postural hypotension regularly when treating CKD patients with BP-lowering drugs 1
Use 24-hour ambulatory BP monitoring when possible for accurate assessment 1
Lifestyle Modifications
Physical Activity
Advise patients to undertake moderate-intensity physical activity for at least 150 minutes per week, adjusted to their cardiovascular and physical tolerance 1, 2, 3, 4
Patients should be advised to avoid sedentary behavior 1, 2, 4
For people at higher risk of falls, provide specific advice on the intensity of physical activity (low, moderate, or vigorous) and the type of exercises (aerobic vs. resistance, or both) 1, 2, 4
Encourage children with CKD to undertake physical activity aiming for WHO-advised levels (≥60 minutes daily) and to achieve a healthy weight 1, 2, 4
Weight Management
Encourage weight loss for patients with obesity and CKD 1, 2, 3
Achieve an optimal body mass index (BMI) 1
Tobacco Cessation
Dietary Management
General Dietary Principles
Advise patients to adopt healthy, diverse diets with higher consumption of plant-based foods compared to animal-based foods and lower consumption of ultra-processed foods 1, 2, 4
Consider a plant-based "Mediterranean-style" diet in addition to lipid-modifying therapy to reduce cardiovascular risk 1, 2
Use renal dietitians or accredited nutrition providers to educate people with CKD about dietary adaptations regarding sodium, phosphorus, potassium, and protein intake, tailored to their individual needs 1, 4
Protein Intake
Maintain protein intake at 0.8 g/kg body weight/day in adults with CKD G3-G5 1, 2, 3, 4
Avoid high protein intake (>1.3 g/kg body weight/day) in adults with CKD at risk of progression 1, 2, 4
In adults with CKD who are willing and able, and who are at risk of kidney failure, consider prescribing, under close supervision, a very low-protein diet (0.3-0.4 g/kg body weight/day) supplemented with essential amino acids or ketoacid analogs (up to 0.6 g/kg body weight/day) 1
Do not prescribe low- or very low-protein diets in metabolically unstable people with CKD 1
Do not restrict protein intake in children with CKD due to the risk of growth impairment, with target protein and energy intake at the upper end of the normal range for healthy children to promote optimal growth 2, 4
In older adults with underlying conditions such as frailty and sarcopenia, consider higher protein and calorie dietary targets 2
Sodium Restriction
Reduce sodium intake to <2 g per day to help control blood pressure and reduce proteinuria 4
Encourage lifestyle modification including sodium restriction 1
Glycemic Control in Diabetic CKD
Implement comprehensive diabetes management according to KDIGO guidelines 3, 4
Use metformin as first-line therapy when eGFR ≥30 ml/min/1.73m² 3, 4
Add SGLT2 inhibitors when eGFR ≥20 ml/min/1.73m² and continue until dialysis or transplantation 3, 4
Consider GLP-1 receptor agonists when SGLT2 inhibitors and metformin are insufficient to meet glycemic targets 4
Target hemoglobin A1c level of approximately 7% 4
Cardiovascular Disease Management
Antiplatelet Therapy
Prescribe oral low-dose aspirin for secondary prevention in people with CKD and established ischemic cardiovascular disease 1, 2, 3, 4
Consider other antiplatelet therapy (e.g., P2Y12 inhibitors) when there is aspirin intolerance 1, 2
Atrial Fibrillation Management
Use non-vitamin K antagonist oral anticoagulants (NOACs) in preference to vitamin K antagonists (e.g., warfarin) for thromboprophylaxis in atrial fibrillation in people with CKD G1-G4 1, 2, 3
NOAC dose adjustment for GFR is required, with caution needed at CKD G4-G5 1
Duration of NOAC discontinuation before elective procedures needs to consider procedural bleeding risk, NOAC prescribed, and level of GFR 1
Coronary Artery Disease
In stable stress-test confirmed ischemic heart disease, an initial conservative approach using intensive medical therapy is an appropriate alternative to an initial invasive strategy 1
Initial management with an invasive strategy may still be preferable for people with CKD with acute or unstable coronary disease, unacceptable levels of angina, left ventricular systolic dysfunction attributable to ischemia, or left main disease 1
Risk Assessment and Monitoring
Regular Monitoring Schedule
Monitor progression of CKD using both blood and urine tests on a regular basis (every 3-6 months), informed by risk of the individual 1, 3, 4
Risk Prediction Tools
Use validated risk equations to estimate absolute risk of kidney failure for individual people to determine referral timing of multidisciplinary care, modality education, and preparation for transition to kidney replacement therapy 1, 3
Estimate 10-year cardiovascular risk using a validated risk tool 1, 2, 3
For cardiovascular risk prediction to guide preventive therapies in people with CKD, use externally validated models that are either developed within CKD populations or that incorporate eGFR and albuminuria 1
For mortality risk prediction to guide discussions about goals of care, use externally validated models that predict all-cause mortality specifically developed in the CKD population 1
Detection and Staging
Test people at risk for and with CKD using both urine albumin measurement and assessment of glomerular filtration rate (GFR) 1, 2, 3
Recognize that small fluctuations in GFR are common and do not necessarily indicate progression 3, 4
Management of CKD-Specific Complications
Metabolic Acidosis
Consider pharmacological treatment with or without dietary intervention when serum bicarbonate <18 mmol/l 4
Monitor treatment to ensure bicarbonate doesn't exceed the upper limit of normal or adversely affect blood pressure, potassium, or fluid status 4
Hyperkalemia
Implement an individualized approach for patients with CKD G3-G5 and hyperkalemia, including dietary and pharmacologic interventions 4
Limit intake of foods rich in bioavailable potassium (e.g., processed foods) for patients with history of hyperkalemia 4
Be aware of factors affecting potassium measurement including diurnal variation, sample type, and medication effects 4
CKD-Mineral Bone Disorder
Monitor calcium, phosphorus, PTH, and vitamin D levels regularly 3
Treat hyperphosphatemia with dietary phosphate restriction and phosphate binders 3
Anemia
- Manage anemia where indicated as part of targeted therapies for complications 1
Referral to Specialist Kidney Care
Indications for Referral
Refer adults with CKD to specialist kidney care services when they have ACR ≥30 mg/g (3 mg/mmol) or PCR ≥200 mg/g (20 mg/mmol) 2
Refer adults with CKD to specialist kidney care services when they have persistent hematuria 2
Refer adults with CKD to specialist kidney care services when they have any sustained decrease in eGFR 2
Multidisciplinary Care
- Referral to providers and programs (e.g., psychologists, renal dietitians or accredited nutrition providers, pharmacists, physical and occupational therapy, and smoking cessation programs) should be offered where indicated and available 1, 4
Preparation for Kidney Replacement Therapy
Use validated risk equations to determine timing for modality education and preparation for transition to kidney replacement therapy 3
Inform people with CKD about the options for kidney replacement therapy and comprehensive conservative care 1
Support comprehensive conservative management as an option for people who choose not to pursue kidney replacement therapy 1
Provide access to resources that enable the delivery of advanced care planning for people with a recognized need for end-of-life care, including those people undergoing comprehensive conservative care 1
Consider both dialysis and transplantation options 3
Implement multidisciplinary care for patients approaching kidney failure 3
Medication Management
Drug Dosing Considerations
Consider GFR when dosing medications cleared by the kidneys 2, 4
For most clinical settings, validated eGFR equations using serum creatinine are appropriate for drug dosing 2
Perform thorough medication review periodically and at transitions of care to assess adherence, continued indication, and potential drug interactions 2
Specific Medication Considerations with RAS Inhibitors
Common side effects of losartan (ARB) in hypertensive patients include upper respiratory infection, dizziness, stuffy nose, and back pain 5
In diabetic patients with nephropathy, common side effects include diarrhea, tiredness, low blood sugar, chest pain, high blood potassium, and low blood pressure 5
Serious adverse effects include allergic reactions (swelling of face, lips, throat, or tongue), low blood pressure, worsening kidney function, and high blood potassium levels 5
Patients should be monitored for postural hypotension and advised to lie down if feeling faint or dizzy 5
Critical Pitfalls to Avoid
Never prescribe NSAIDs in CKD due to nephrotoxicity risk and potential for acute kidney injury—use low-dose colchicine or glucocorticoids instead for inflammatory conditions like acute gout 2
Do NOT use agents to lower serum uric acid in CKD patients with asymptomatic hyperuricemia to delay CKD progression 2
Do not discontinue RAS inhibitors due to modest increases in serum creatinine or potassium unless there are specific contraindications 2
Do not restrict protein in children with CKD or in adults who are cachexic, sarcopenic, or undernourished 1, 2
Avoid high-protein intake (>1.3 g/kg body weight/day) in adults with CKD at risk of progression 1, 2