Treatment of Chronic Kidney Disease
Treat CKD patients with a comprehensive strategy that includes blood pressure control with ACE inhibitors or ARBs (especially if albuminuria is present), statin therapy for cardiovascular protection, lifestyle modifications including 150 minutes weekly of moderate exercise, dietary protein restriction to 0.8 g/kg/day, and regular monitoring for metabolic complications—this approach reduces progression to kidney failure and cardiovascular mortality. 1, 2
Blood Pressure Management
Target blood pressure <130/80 mmHg in patients with albuminuria ≥30 mg/24 hours, and <140/90 mmHg in those without albuminuria. 1, 2, 3
- Initiate ACE inhibitors or ARBs as first-line therapy for all patients with diabetes, hypertension, and albuminuria, titrating to the highest approved dose tolerated. 1
- Monitor serum creatinine and potassium within 2-4 weeks after starting or increasing doses of ACE inhibitors or ARBs. 1, 4
- Continue therapy unless creatinine rises >30% within 4 weeks of initiation or dose increase. 1, 4
- Do not combine ACE inhibitors with ARBs—this increases hyperkalemia and acute kidney injury risk without additional benefit. 4
The evidence strongly supports renin-angiotensin system blockade as foundational therapy, with decades of data from ACE inhibitor trials in type 1 diabetes and ARB trials in type 2 diabetes demonstrating slowed progression and reduced proteinuria. 1
Cardiovascular Risk Reduction
Prescribe statins or statin/ezetimibe combination for all adults ≥50 years with eGFR <60 ml/min/1.73 m² (CKD G3a-G5). 2, 3, 4
- For adults 18-49 years with CKD, initiate statins if they have coronary disease, diabetes, prior stroke, or 10-year coronary event risk >10%. 3, 4
- Choose statin-based therapies that maximize absolute LDL-cholesterol reduction. 2
- Use low-dose aspirin for secondary prevention in patients with established ischemic cardiovascular disease, but not for primary prevention. 4
Lifestyle Modifications
Advise moderate-intensity physical activity for at least 150 minutes per week, adjusted to cardiovascular and physical tolerance. 1, 2, 3
- Patients should avoid sedentary behavior entirely. 1, 2
- Encourage weight loss in patients with obesity through diet, physical activity, and behavioral therapy. 1, 2, 3
- Promote complete smoking cessation. 1, 2
- For children with CKD, encourage ≥60 minutes daily of physical activity. 1, 2
Dietary Management
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) in adults with CKD at risk of progression. 1, 2, 4
- For patients at high risk of kidney failure who are willing and able, consider a very low-protein diet (0.3-0.4 g/kg body weight/day) with essential amino acid or ketoacid analog supplementation under close supervision. 1, 2
- Do not restrict protein in children with CKD due to growth impairment risk. 2
- Advise adoption of healthy, diverse diets with higher consumption of plant-based foods compared to animal-based foods and lower consumption of ultra-processed foods. 1, 2, 3
- Limit sodium intake to <2 g per day (equivalent to <90 mmol/day or <5 g sodium chloride/day). 3, 4
The dietary recommendations reflect a shift toward plant-based eating patterns, which align with both kidney protection and cardiovascular risk reduction goals. 1
Management of Metabolic Complications
Provide pharmacological treatment with or without dietary intervention when serum bicarbonate <18 mmol/L to prevent acidosis. 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
- Treat symptomatic hyperuricemia (gout) with urate-lowering therapy, preferring xanthine oxidase inhibitors over uricosuric agents. 2, 3
- Do not prescribe urate-lowering therapy for asymptomatic hyperuricemia to delay CKD progression—there is no evidence of benefit. 2
- Recommend non-pharmacological measures for gout prevention including limiting alcohol, meat, and high-fructose corn syrup. 2
- Monitor for and treat anemia, CKD-mineral and bone disorders, potassium disorders, and acidosis. 1, 5
Risk Stratification and Monitoring
Use validated risk prediction equations incorporating eGFR and albuminuria to guide management intensity. 1, 3
- A 5-year kidney failure risk of 3-5% determines need for nephrology referral. 1
- A 2-year kidney failure risk >10% triggers multidisciplinary care initiation. 1, 2, 3
- A 2-year kidney failure risk >40% initiates kidney replacement therapy preparation including vascular access planning or transplant referral. 1, 2
- For cardiovascular risk prediction, use externally validated models developed specifically for CKD populations that incorporate both eGFR and albuminuria. 1, 2, 3
- Perform regular risk factor reassessment every 3-6 months. 1, 4
Medication Management
Adjust all medication dosages according to kidney function to prevent toxicity. 2, 3, 5
- Avoid NSAIDs as they worsen kidney function and interfere with antihypertensive medication effectiveness. 4, 5
- For patients with atrial fibrillation, prefer non-vitamin K antagonist oral anticoagulants (NOACs) over vitamin K antagonists, with appropriate dose adjustments based on GFR. 2, 3
- Advise contraception in women receiving ACE inhibitors or ARBs and discontinue these agents in women considering pregnancy or who become pregnant. 1
Diabetes-Specific Management
For patients with type 2 diabetes and CKD, use SGLT2 inhibitors when eGFR ≥20 ml/min/1.73 m² and continue until dialysis or transplantation. 1, 4
- Use metformin as first-line therapy when eGFR ≥30 ml/min/1.73 m². 1, 3
- Add GLP-1 receptor agonists if SGLT2 inhibitors and metformin are insufficient to meet glycemic targets or if patients cannot use SGLT2 inhibitors or metformin. 1, 4
- Target hemoglobin A1c of approximately 7%. 3
- Consider adding a nonsteroidal mineralocorticoid receptor antagonist for patients with type 2 diabetes and persistent albuminuria >30 mg/g (>3 mg/mmol) despite first-line therapy. 1
The diabetes management recommendations represent a major evolution, with SGLT2 inhibitors now recognized as foundational therapy based on robust cardiovascular and kidney outcome trials. 1
Nephrology Referral Criteria
Refer to nephrology when 5-year kidney failure risk is 3-5%, or when eGFR <30 ml/min/1.73 m², or albuminuria ≥300 mg per 24 hours. 3, 5, 6
- All patients with CKD stages 4-5 should be referred to nephrology. 7
- Refer patients with rapid decline in eGFR or acute kidney injury. 5, 6
- Utilize renal dietitians for specialized nutritional counseling. 1, 3
- Establish multidisciplinary CKD units including nephrologist, nephrology nurse, dietitian, and social worker for cost-effective integrated care. 7
Quality of Life Considerations
Regularly screen for symptoms using validated tools and maximize health-related quality of life, physical function, capacity to work, and ability to socialize. 1, 3