Primary Treatment for Chronic Kidney Disease to Slow Progression
ACE inhibitors or ARBs are the primary first-line treatment to slow CKD progression, particularly in patients with albuminuria ≥300 mg/g creatinine, and should be combined with blood pressure control to ≤130/80 mmHg when albuminuria is present. 1, 2, 3
First-Line Pharmacologic Therapy
ACE inhibitors or ARBs form the cornerstone of CKD treatment because they reduce proteinuria and consistently slow progression in both diabetic and non-diabetic nephropathy through mechanisms beyond blood pressure reduction alone. 2, 3, 4
Specific Indications by Albuminuria Level:
For albuminuria ≥300 mg/g creatinine: ACE inhibitors or ARBs are strongly recommended as first-line therapy to prevent kidney disease progression and reduce cardiovascular events. 1, 2, 3
For albuminuria 30-299 mg/g creatinine: ACE inhibitor or ARB therapy at maximum tolerated doses reduces progression to more advanced albuminuria (≥300 mg/g), slows CKD progression, and reduces cardiovascular events, though it has not proven to reduce progression to end-stage kidney disease at this level. 1, 3
Target reduction: Aim for ≥30% reduction in urinary albumin excretion, which directly correlates with kidney protection and reduced cardiovascular risk. 3
Blood Pressure Management
Target blood pressure ≤130/80 mmHg for patients with albuminuria ≥30 mg/24 hours to slow CKD progression. 1, 3
For patients with albuminuria <30 mg/24 hours, target BP ≤140/90 mmHg. 2, 3
Blood pressure control is critical in breaking the vicious cycle between hypertension and CKD. 2
Most patients will require multiple antihypertensive agents to achieve these targets; thiazide-like diuretics and dihydropyridine calcium channel blockers can be added to ACE inhibitor/ARB therapy. 1
Additional Pharmacologic Interventions for Diabetic CKD
SGLT2 inhibitors should be added for diabetic CKD patients with eGFR ≥20 mL/min/1.73 m² as they provide additional nephroprotection beyond ACE inhibitors/ARBs. 1, 3
Metformin is recommended as first-line glucose management when eGFR ≥30 mL/min/1.73 m². 3
Target HbA1c approximately 7% to reduce risk and slow CKD progression, though intensive glucose control requires 2-10 years to manifest improved kidney outcomes. 1, 3
Lifestyle and Dietary Interventions
Sodium restriction to <2,300 mg/day (ideally <2 g/day) helps manage blood pressure, reduces proteinuria, and slows progression. 1, 2, 3
Protein intake should not exceed 0.8 g/kg/day for stage 3 or higher CKD, though reducing below this level is not routinely recommended as evidence is limited and graded as "opinion" only for diabetic CKD. 1, 3
Cardiovascular Risk Reduction
Statin therapy is recommended for all adults ≥50 years with CKD regardless of GFR category, as cardiovascular disease is a major cause of mortality in CKD patients. 2, 3
- For adults 18-49 years, statins should be used if they have coronary disease, diabetes, prior stroke, or 10-year coronary event risk >10%. 3
Monitoring Strategy
Monitor urinary albumin and eGFR 1-4 times per year depending on CKD stage to track disease progression and treatment response. 2, 3
- Regular monitoring is essential as all CKD patients are at increased risk of acute kidney injury, which can accelerate progression. 2
Important Clinical Caveats
ACE inhibitors and ARBs are considered to have similar benefits and risks in CKD treatment, so either class is appropriate as first-line therapy. 1
The degree of proteinuria reduction correlates directly with kidney protection, making this a critical therapeutic target alongside blood pressure control. 2
Treatment effects require time to manifest: There is a lag time of at least 2 years in type 2 diabetes to over 10 years in type 1 diabetes for intensive glucose control to show improved kidney outcomes. 1
Avoid combining ACE inhibitors with ARBs, as dual RAAS blockade increases adverse effects without additional benefit. 1