What is the best standard for CKD (Chronic Kidney Disease) patients to follow their doctor's orders?

Best Standard for CKD Patients Following Doctor's Orders

CKD patients should follow a structured, evidence-based management protocol centered on blood pressure control with RAS inhibitors, SGLT2 inhibitors, dietary modifications (protein ≤0.8 g/kg/day, sodium <2 g/day), statin therapy, regular monitoring of kidney function and electrolytes, and strict avoidance of nephrotoxic medications like NSAIDs. 1

Core Treatment Components

Blood Pressure Management

• Target systolic BP <120 mmHg when tolerated using standardized office measurements 1
• For patients with albuminuria ≥30 mg/24h, target BP ≤130/80 mmHg 1
• For patients with albuminuria <30 mg/24h, maintain BP ≤140/90 mmHg 1
• Monitor for postural hypotension regularly, especially in elderly patients 1

RAS Inhibitor Therapy (ACE-I or ARB)

• Start ACE-I or ARB for all patients with moderately-to-severely increased albuminuria (≥30 mg/g) with or without diabetes 1
• Use the highest approved tolerated dose, as trial benefits were achieved at these doses 1
• Continue therapy even when eGFR falls below 30 ml/min/1.73 m² 1, 2
• Check BP, creatinine, and potassium within 2-4 weeks of initiation or dose increase 1
• Continue unless creatinine rises >30% within 4 weeks of starting treatment 1, 2

SGLT2 Inhibitor Therapy

• Initiate SGLT2 inhibitor in all type 2 diabetes patients with eGFR ≥20 ml/min/1.73 m² 1
• Start SGLT2 inhibitor in non-diabetic patients with eGFR ≥20 ml/min/1.73 m² and albuminuria ≥200 mg/g 1
• Continue even if eGFR falls below 20 ml/min/1.73 m² unless not tolerated or dialysis initiated 1
• Withhold during prolonged fasting, surgery, or critical illness due to ketosis risk 1

Dietary Modifications

• Limit protein intake to 0.8 g/kg body weight/day in CKD G3-G5 1
• Avoid high protein intake >1.3 g/kg/day 1
• Restrict sodium to <2 g/day (or <5 g sodium chloride/day) 1
• Limit foods rich in bioavailable potassium (especially processed foods) if history of hyperkalemia 1

Lipid Management

• Prescribe statin or statin/ezetimibe combination for all patients ≥50 years with eGFR <60 ml/min/1.73 m² 1
• For patients ≥50 years with eGFR ≥60 ml/min/1.73 m², use statin alone 1
• For patients 18-49 years, prescribe statin if they have coronary disease, diabetes, prior stroke, or 10-year cardiovascular risk >10% 1

Critical Medication Avoidance

NSAIDs Must Be Completely Avoided

• Never prescribe NSAIDs in CKD patients due to nephrotoxicity risk 3
• NSAIDs cause acute kidney injury, progressive GFR loss, electrolyte derangements, hypervolemia, and worsening heart failure 3
• Use acetaminophen as first-line analgesic (maximum 2-3 grams daily with dose reduction in advanced CKD) 3

Monitoring Requirements

Regular Laboratory Testing

• Monitor serum creatinine and potassium when using ACE-I, ARB, or diuretics 1
• Assess for CKD progression by tracking GFR category changes and sustained eGFR decline ≥5 ml/min/1.73 m²/year 1
• Screen for complications: hyperkalemia, metabolic acidosis, hyperphosphatemia, vitamin D deficiency, anemia 4

Nephrology Referral Criteria

• Refer to nephrologist when eGFR <30 ml/min/1.73 m² 1
• Promptly refer for uncertain etiology, difficult management issues, or rapidly progressing disease 1
• High-risk patients (eGFR <30 ml/min/1.73 m², albuminuria ≥300 mg/24h, or rapid eGFR decline) require urgent referral 4

Additional Therapies for Type 2 Diabetes

GLP-1 Receptor Agonists

• Use long-acting GLP-1 RA if glycemic targets not met despite metformin and SGLT2 inhibitor 1
• Prioritize agents with documented cardiovascular benefits 1

Nonsteroidal Mineralocorticoid Receptor Antagonists

• Consider finerenone for type 2 diabetes patients with eGFR >25 ml/min/1.73 m², normal potassium, and albuminuria >30 mg/g despite maximum RAS inhibitor dose 1
• Monitor potassium regularly after initiation 1

Common Pitfalls to Avoid

• Do not discontinue RAS inhibitors for minor creatinine increases ≤30% without volume depletion 1
• Do not stop RAS inhibitors solely because eGFR falls below 30 ml/min/1.73 m² 1, 2
• Manage hyperkalemia with potassium binders, dietary restriction, and diuretics rather than stopping RAS inhibitors 1, 2
• Do not restrict protein in children with CKD due to growth impairment risk 1
• Avoid high-intensity BP lowering in frail patients, those with high fall risk, or symptomatic postural hypotension 1