What is the management plan for a patient with chronic kidney disease, mineral bone disorder, newly diagnosed hypertension, and moderate anemia?

Management of CKD with Mineral Bone Disorder, Hypertension, and Anemia

For this 36-37 year old patient with advanced CKD, initiate an ACE inhibitor or ARB at maximum tolerated dose as first-line antihypertensive therapy targeting systolic BP <120 mmHg, start erythropoiesis-stimulating agent (ESA) when hemoglobin falls below 10 g/dL with a target to avoid transfusions (not exceeding 11 g/dL), and aggressively manage mineral bone disorder with phosphate binders and vitamin D therapy while monitoring calcium, phosphorus, and PTH levels. 1, 2, 3

Blood Pressure Management

Target Blood Pressure

• Aim for systolic BP <120 mmHg if tolerated, as this provides superior cardiovascular and renal protection compared to older targets of <140/90 mmHg 1, 2
• For patients who cannot tolerate intensive control, a minimum target of <130/80 mmHg is acceptable 1, 2

First-Line Antihypertensive Selection

• Start with an ACE inhibitor or ARB at the maximum approved tolerated dose as first-line therapy 1, 2
• ACE inhibitors/ARBs provide renoprotection beyond blood pressure lowering and should be continued until dialysis or transplantation 1
• Monitor serum creatinine and potassium within 2-4 weeks of initiation or dose increase 2, 4
• Continue therapy even if creatinine rises up to 30% within 4 weeks, as this represents hemodynamic changes rather than kidney injury 2

Add-On Therapy Algorithm

When BP goal is not achieved with ACE inhibitor/ARB alone:

1. Second-line: Add a long-acting dihydropyridine calcium channel blocker OR thiazide-type diuretic 1, 2
2. Third-line: Add the remaining class not yet used (CCB or diuretic) 1, 2
3. Most CKD patients require 2-3 agents to achieve BP <120 mmHg 4

Critical Contraindications

• Never combine ACE inhibitor + ARB together - this increases hyperkalemia, hypotension, and acute kidney injury without additional benefit 2, 4, 5
• Do not add direct renin inhibitors to ACE inhibitor or ARB therapy 2

Anemia Management

When to Initiate ESA Therapy

• Initiate ESA when hemoglobin is <10 g/dL in adult CKD patients 3
• For patients not on dialysis, consider whether the rate of hemoglobin decline indicates likelihood of requiring transfusion before starting 3

Target Hemoglobin and Dosing

• Use the lowest ESA dose sufficient to reduce need for RBC transfusions 3
• Do NOT target hemoglobin >11 g/dL - trials show increased risks of death, cardiovascular events, and stroke at higher targets 3
• If hemoglobin approaches or exceeds 11 g/dL, reduce or interrupt ESA dosing 3

Recommended Starting Dose

• Epoetin alfa: 50-100 Units/kg three times weekly (intravenously or subcutaneously) 3
• Intravenous route is preferred for hemodialysis patients 3

Monitoring and Dose Adjustment

• Monitor hemoglobin weekly until stable, then at least monthly 3
• If hemoglobin rises >1 g/dL in any 2-week period, reduce dose by 25% or more 3
• If hemoglobin increases <1 g/dL after 4 weeks, increase dose by 25% 3
• If no response after 12 weeks of dose escalation, further increases are unlikely to help and may increase risks - evaluate other causes of anemia 3

Iron Supplementation - Mandatory

• Evaluate iron status before and during all ESA therapy 3
• Administer supplemental iron when ferritin <100 mcg/L or transferrin saturation <20% 3
• The majority of CKD patients require supplemental iron during ESA therapy 3

Mineral Bone Disorder Management

Monitoring Parameters

• Measure serum calcium, phosphorus, PTH, and total CO2 at baseline 1
• Frequency depends on CKD stage - more frequent monitoring needed as kidney function declines 1

Phosphorus Control

• Target serum phosphorus within normal range using phosphate binders 6
• Non-calcium-containing binders (sevelamer, lanthanum carbonate) are preferred to avoid calcium overload 6
• Calcium-based binders may be used but monitor total calcium load carefully 6

PTH Management

• Use vitamin D receptor activators (paricalcitol, doxercalciferol) to control PTH production 6
• These agents have fewer calcemic and phosphatemic effects compared to traditional vitamin D 6
• Consider calcimimetics for secondary hyperparathyroidism refractory to vitamin D therapy 6

Metabolic Acidosis Correction

• Maintain serum total CO2 >22 mEq/L 1
• Administer supplemental alkali salts if needed to achieve this target 1
• Correcting acidosis helps prevent bone disease progression 1

Additional Cardiovascular Risk Modification

SGLT2 Inhibitors

• Initiate SGLT2 inhibitor and continue until dialysis or transplant as first-line therapy for most CKD patients 1
• Provides kidney protection, cardiovascular protection, and blood pressure lowering 1

Statin Therapy

• Start moderate- or high-intensity statin for cardiovascular risk reduction 1
• Add ezetimibe or PCSK9 inhibitor based on ASCVD risk and lipid levels 1

Lifestyle Modifications

• Recommend 150 minutes per week of moderate-intensity physical activity 1
• Advise sodium intake <2 g/day (or <90 mmol/day, or <5 g sodium chloride/day) 1
• Maintain protein intake at 0.8 g/kg/day - avoid high protein intake >1.3 g/kg/day 1
• Encourage plant-based foods over animal-based foods and minimize ultra-processed foods 1

Common Pitfalls to Avoid

• Do not discontinue antihypertensives simply because BP falls below target if patient tolerates therapy without adverse effects 1, 2
• Do not restrict protein intake in patients with malnutrition, sarcopenia, or frailty 1
• Inadequate diuretic dosing leads to fluid retention and poor BP control, while excessive dosing causes volume contraction and worsening renal function 2
• Do not target hemoglobin >11 g/dL with ESAs - this increases mortality and cardiovascular events 3
• Always supplement iron during ESA therapy - most patients require it and ESAs are ineffective without adequate iron stores 3
• Avoid calcium overload when treating mineral bone disorder - use non-calcium phosphate binders preferentially 6

Nephrology Referral

• Refer to nephrologist immediately given eGFR likely <30 mL/min/1.73 m² based on clinical presentation 1, 5
• Nephrologist involvement improves management of complications, optimizes medication use, and facilitates preparation for renal replacement therapy 1