What is the initial approach to managing kidney disease?

Initial Management of Chronic Kidney Disease

The initial approach to managing kidney disease centers on a comprehensive risk-reduction strategy combining lifestyle modifications with first-line pharmacotherapy including SGLT2 inhibitors, RAS inhibitors (for hypertension/albuminuria), and statins, alongside aggressive blood pressure control targeting <120 mmHg systolic. 1

Foundation: Lifestyle Modifications

All patients with CKD require baseline lifestyle interventions before layering pharmacotherapy 1:

• Physical activity: 150 minutes per week of moderate-intensity exercise 1
• Dietary approach: Plant-based diet with higher consumption of plant-based foods compared to animal-based foods, lower ultra-processed food intake 1
• Protein intake: Maintain 0.8 g/kg/day in CKD G3-G5; avoid high protein intake >1.3 g/kg/day 1
• Tobacco cessation: Complete avoidance of all tobacco products to minimize cardiovascular, respiratory disease, and cancer risks 1
• Weight management: Achieve weight appropriate for age, gender, and comorbidities 1

First-Line Pharmacotherapy

SGLT2 Inhibitors

SGLT2 inhibitors should be initiated as first-line therapy for most CKD patients and continued until dialysis or transplantation 1:

• Initiate when eGFR ≥20 ml/min/1.73 m² 1
• Continue through CKD stages G4-G5 until dialysis initiation 1
• Provides kidney and heart protection independent of diabetes status 1
• Discontinue at dialysis initiation 1

Blood Pressure Management

Target systolic blood pressure <120 mmHg for most patients 1:

• RAS inhibitors (ACE inhibitors or ARBs): First-line when albuminuria is present, at maximum tolerated dose 1, 2
• Add dihydropyridine calcium channel blockers and/or diuretics if needed to achieve BP targets 1
• For patients with diabetes and albuminuria, consider adding nonsteroidal mineralocorticoid receptor antagonists 1
• Steroidal MRA may be added for resistant hypertension 1

Common pitfall: Do not discontinue RAS inhibitors prematurely if creatinine increases up to 30% from baseline—this is acceptable and expected 3, 2

Lipid Management

Statin-based therapy is recommended for cardiovascular risk reduction 1:

• Moderate- or high-intensity statin for all patients with CKD 1
• Add ezetimibe or PCSK9 inhibitors based on ASCVD risk and lipid levels 1
• Do not initiate statins in patients beginning dialysis, though continue if already prescribed 1

Glycemic Control (for Diabetic CKD)

Follow KDIGO Diabetes Guidelines with specific agents 1:

• Metformin: First-line when eGFR ≥30 ml/min/1.73 m² 1
• GLP-1 receptor agonists: Preferred glucose-lowering drug if SGLT2i/metformin insufficient or not tolerated 1
• Optimize glycemic control to slow CKD progression 1, 4

Detection and Staging

Test all at-risk patients using both urine albumin measurement and eGFR assessment 1:

• Measure serum creatinine to calculate eGFR 1
• Quantify albuminuria using urine albumin-to-creatinine ratio 1
• If eGFR 45-59 ml/min/1.73 m², order cystatin C to confirm GFR estimation 1
• Identify and treat specific underlying cause of CKD 1

Regular Monitoring

Reassess risk factors every 3-6 months 1:

• Monitor serum creatinine, eGFR, and albuminuria 1
• Check blood pressure regularly, preferably with 24-hour ambulatory monitoring 3
• Monitor potassium levels, especially with RAS inhibitors and MRAs 1
• Assess for CKD complications including anemia and mineral bone disorder 1

Medication Safety

Review all medications for appropriate dosing and nephrotoxicity 1, 3:

• Avoid NSAIDs as they worsen kidney function and increase cardiovascular risk 1, 3, 4
• Adjust medication doses based on kidney function 1, 3
• Monitor for drug interactions, particularly with RAS inhibitors and potassium-sparing agents 1

Additional Interventions

• Treat metabolic acidosis when present 1
• Antiplatelet therapy: Low-dose aspirin for secondary prevention in established ASCVD; consider for primary prevention in high-risk patients 1
• Avoid nephrotoxins and adjust medication dosages appropriately 1

Common Pitfalls to Avoid

• Do not delay SGLT2 inhibitor initiation—these agents have proven benefits in slowing CKD progression 3
• Do not stop RAS inhibitors for modest creatinine elevation (up to 30% increase is acceptable) 3, 2
• Do not ignore modifiable risk factors such as smoking, obesity, and sedentary lifestyle 3
• Do not prescribe low-protein diets in metabolically unstable patients 1
• Do not restrict protein intake in children due to growth risk 1