What is the initial management for patients with Chronic Kidney Disease (CKD)?

Initial Management of Chronic Kidney Disease

Start SGLT2 inhibitors immediately for most CKD patients (eGFR ≥20 ml/min/1.73 m²), combined with ACE inhibitor or ARB at maximum tolerated dose when albuminuria or hypertension is present, alongside statin therapy for all patients ≥50 years with eGFR <60 ml/min/1.73 m². 1, 2

Core Pharmacologic Strategy

SGLT2 Inhibitors - First-Line for Most Patients

• Initiate SGLT2 inhibitors in all adults with type 2 diabetes and CKD with eGFR ≥20 ml/min/1.73 m² 1
• For non-diabetic CKD patients, start SGLT2 inhibitors when eGFR ≥20 ml/min/1.73 m² AND either:
  • Urine albumin-to-creatinine ratio (ACR) ≥200 mg/g (≥20 mg/mmol), OR
  • Heart failure is present (regardless of albuminuria level) 1
• Consider SGLT2 inhibitors for patients with eGFR 20-45 ml/min/1.73 m² and ACR <200 mg/g 1
• Continue SGLT2 inhibitors even if eGFR falls below 20 ml/min/1.73 m² unless not tolerated or kidney replacement therapy is initiated 1
• Withhold temporarily during prolonged fasting, surgery, or critical illness due to ketosis risk 1
• The reversible eGFR decrease upon initiation is expected and not an indication to discontinue 1

RAS Inhibition - Essential for Albuminuria and Hypertension

• Start ACE inhibitor or ARB for patients with severely increased albuminuria (ACR ≥300 mg/24h or ≥300 mg/g) regardless of diabetes status 1
• Start ACE inhibitor or ARB for diabetic patients with moderately-to-severely increased albuminuria (ACR ≥30 mg/24h) 1
• Consider ACE inhibitor or ARB for non-diabetic patients with moderately increased albuminuria (ACR 30-300 mg/24h) 1
• Titrate to the highest approved dose that is tolerated - proven benefits were achieved at these doses in trials 1
• Continue ACE inhibitor or ARB even when eGFR falls below 30 ml/min/1.73 m² 1
• Never combine ACE inhibitor + ARB + direct renin inhibitor - this increases harm without benefit 1, 3

Monitoring After RAS Inhibition Initiation

• Check blood pressure, serum creatinine, and potassium within 2-4 weeks of starting or increasing dose 1, 3
• Continue therapy unless creatinine rises >30% within 4 weeks 1, 3
• Manage hyperkalemia with potassium-lowering measures rather than stopping RAS inhibition when possible 1
• Consider dose reduction or discontinuation only for symptomatic hypotension, uncontrolled hyperkalemia despite treatment, or uremic symptoms with eGFR <15 ml/min/1.73 m² 1

Blood Pressure Targets

Target Based on Albuminuria Status

• For patients WITHOUT albuminuria (<30 mg/24h): Target BP ≤140/90 mmHg 1, 4
• For patients WITH albuminuria (≥30 mg/24h): Target BP ≤130/80 mmHg 1, 4
• The 2024 KDIGO guideline represents a shift toward more aggressive BP control compared to 2012 recommendations 1, 5

Antihypertensive Drug Selection

• Use ACE inhibitor or ARB as first-line when albuminuria is present 1, 4
• Add additional agents (thiazide diuretics, calcium channel blockers) as needed to reach target 6
• Diuretics are cornerstone therapy for volume management in CKD 6
• Monitor for postural hypotension regularly when treating with BP-lowering drugs 1

Cardiovascular Risk Reduction

Statin Therapy - Mandatory for Most CKD Patients

• Prescribe statin or statin/ezetimibe combination for all adults ≥50 years with eGFR <60 ml/min/1.73 m² (CKD G3a-G5) 4, 2
• Choose regimens that maximize absolute LDL-cholesterol reduction 4, 2
• Consider statin therapy for adults 18-49 years with CKD who have coronary disease, diabetes, prior stroke, or 10-year cardiovascular risk >10% 3

Antiplatelet Therapy

• Prescribe low-dose aspirin for secondary prevention in CKD patients with established ischemic cardiovascular disease 2, 3
• Aspirin is NOT recommended for primary prevention in CKD 3
• Consider alternative antiplatelet therapy (P2Y12 inhibitors) if aspirin intolerance 2

Anticoagulation for Atrial Fibrillation

• Prefer non-vitamin K antagonist oral anticoagulants (NOACs) over warfarin for CKD G1-G4 2, 3
• Adjust NOAC doses appropriately based on GFR 4

Lifestyle Modifications

Physical Activity

• Recommend moderate-intensity physical activity for at least 150 minutes per week, adjusted to cardiovascular and physical tolerance 4, 2, 3
• Advise patients to avoid sedentary behavior 4, 2
• For patients at higher risk of falls, provide specific guidance on exercise intensity and type 2

Dietary Recommendations

• Adopt healthy, diverse diets with higher plant-based foods and lower ultra-processed foods 4, 2, 3
• Consider plant-based "Mediterranean-style" diet for cardiovascular risk reduction 4, 2
• Maintain protein intake at 0.8 g/kg body weight/day for CKD G3-G5 4, 2, 3
• Avoid high protein intake (>1.3 g/kg/day) in patients at risk of progression 4, 2, 3
• Limit sodium intake to <2 g per day 1
• Restrict high-potassium foods in patients with history of hyperkalemia 4

Weight and Smoking

• Encourage weight loss for patients with obesity and CKD 4, 2
• Promote smoking cessation 4
• Target healthy BMI of 20-25 kg/m² 1

Diabetes Management in CKD

Glycemic Control

• Target hemoglobin A1c of approximately 7% 1
• SGLT2 inhibitors are first-line for diabetic CKD with eGFR ≥20 ml/min/1.73 m² 1, 3
• Consider GLP-1 receptor agonists for cardiovascular risk reduction 3
• Metformin is appropriate for eGFR ≥45 ml/min/1.73 m² 3

Monitoring for CKD Complications

Metabolic Complications to Monitor

• Hyperkalemia 4, 7
• Metabolic acidosis (treat if serum bicarbonate <18 mmol/L) 4
• Hyperphosphatemia 4, 7
• Vitamin D deficiency 4, 7
• Secondary hyperparathyroidism 4, 7
• Anemia 4, 7

Monitoring Frequency

• The 2012 KDIGO guideline provides a GFR and albuminuria grid indicating monitoring frequency (1-4 times per year based on risk category) 1
• Higher GFR categories with lower albuminuria require less frequent monitoring 1
• Regular risk factor reassessment every 3-6 months 3

Critical Medication Considerations

Drugs to AVOID

• Never prescribe NSAIDs in CKD - they cause nephrotoxicity and acute kidney injury risk 2, 3
• Use low-dose colchicine or glucocorticoids instead for conditions like acute gout 2
• Do NOT use urate-lowering therapy for asymptomatic hyperuricemia to delay CKD progression 4, 2

Medication Dosing Adjustments

• Adjust medication dosages according to kidney function for renally-cleared drugs 4, 2
• Use validated eGFR equations for drug dosing in most clinical settings 2
• Perform thorough medication review periodically and at care transitions 2

Referral to Nephrology

Indications for Specialist Referral

• ACR ≥30 mg/g (3 mg/mmol) or protein-to-creatinine ratio ≥200 mg/g (20 mg/mmol) 2
• Persistent hematuria 2
• Any sustained decrease in eGFR 2
• eGFR <30 ml/min/1.73 m² 7
• Albuminuria ≥300 mg per 24 hours 7
• Rapid decline in eGFR 7

Risk Stratification

Use Validated Risk Prediction Tools

• Apply kidney failure risk equation to identify high-risk patients 4, 2
• 2-year kidney failure risk >10% indicates need for multidisciplinary care 4
• 2-year kidney failure risk >40% indicates need for kidney replacement therapy preparation 4
• Estimate 10-year cardiovascular risk using validated tools incorporating eGFR and albuminuria 4, 2

Common Pitfalls to Avoid

• Do not discontinue RAS inhibitors for modest creatinine or potassium increases unless specific contraindications exist 2
• Do not combine ACE inhibitor + ARB - this increases hyperkalemia and acute kidney injury risk without benefit 1, 3
• Do not misinterpret small GFR fluctuations as progression - require both GFR category change AND ≥25% change in eGFR 1
• Do not restrict protein intake in children with CKD due to growth impairment risk 4, 2
• Monitor for orthostatic hypotension when initiating or increasing antihypertensive doses 3