What is the best approach to manage Chronic Kidney Disease (CKD)?

Management of Chronic Kidney Disease (CKD)

Implement a comprehensive treatment strategy targeting blood pressure control with ACE inhibitors or ARBs, cardiovascular risk reduction with statins, lifestyle modifications including sodium restriction and exercise, and regular monitoring for metabolic complications to reduce CKD progression and improve mortality and quality of life outcomes. 1

Blood Pressure Management

Target blood pressure <130/80 mmHg in patients with albuminuria ≥30 mg/24 hours and <140/90 mmHg in those without albuminuria. 2, 1

• Use angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARBs) as first-line therapy, particularly in patients with albuminuria >300 mg/24 hours 2, 1
• ACEi/ARBs provide superior nephroprotection compared to other antihypertensive classes by controlling both blood pressure and proteinuria 3
• Add dihydropyridine calcium channel blockers and/or diuretics as needed to achieve blood pressure targets 4
• Do not combine ACE inhibitors with ARBs as evidence is insufficient to recommend this combination for preventing CKD progression 2

Cardiovascular Risk Reduction

Prescribe statin therapy for all adults ≥50 years with CKD regardless of GFR category. 2, 1

• For adults 18-49 years with CKD, initiate statins if they have coronary disease, diabetes, prior stroke, or 10-year coronary event risk >10% 2, 1
• Consider adding ezetimibe to maximize LDL cholesterol reduction and achieve the largest treatment benefits 2
• Consider PCSK-9 inhibitors in patients with CKD who have an indication for their use 2
• Persons with CKD are more likely to have a cardiovascular event than to progress to end-stage renal disease 2

Lifestyle Modifications

Advise patients to perform moderate-intensity physical activity for at least 150 minutes per week, adjusted to cardiovascular and physical tolerance. 1, 4

• Limit sodium intake to <2 g per day (equivalent to <90 mmol/day or <5 g sodium chloride/day) 2, 1, 4
• Encourage weight loss in patients with obesity through diet, physical activity, and behavioral therapy 1, 4
• Recommend smoking cessation as tobacco use accelerates CKD progression 4
• Avoid sedentary behavior with specific guidance on exercise intensity based on fall risk 4

Dietary Management

Adopt healthy, diverse diets with higher consumption of plant-based foods compared to animal-based foods and lower consumption of ultraprocessed foods. 1, 4

• Maintain protein intake at 0.8 g/kg body weight/day in adults with CKD G3-G5 1, 4
• Avoid high protein intake (>1.3 g/kg/day) in those at risk of progression 4
• Refer to renal dietitians or accredited nutrition providers for specialized nutritional counseling 1, 4

Glycemic Control in Diabetic CKD

Target hemoglobin A1c of approximately 7%. 2, 1

• Use metformin as first-line therapy when eGFR ≥30 ml/min/1.73m² 1, 4
• Add SGLT2 inhibitors when eGFR ≥20 ml/min/1.73m² and continue until dialysis or transplantation 4
• Consider GLP-1 receptor agonists when SGLT2 inhibitors and metformin are insufficient to meet glycemic targets 4

Management of Metabolic Complications

Provide pharmacological treatment with or without dietary intervention when serum bicarbonate <18 mmol/L (threshold moved from <22 mmol/L in previous guidelines). 2, 1

• Monitor treatment to ensure bicarbonate doesn't exceed the upper limit of normal or adversely affect blood pressure, potassium, or fluid status 4
• Treat symptomatic hyperuricemia (gout) with urate-lowering therapy, preferring xanthine oxidase inhibitors over uricosuric agents 2, 1
• Do not use agents to lower serum uric acid in patients with asymptomatic hyperuricemia to delay CKD progression 2

Hyperkalemia Management

• Implement an individualized approach including dietary and pharmacologic interventions 1, 4
• Limit intake of foods rich in bioavailable potassium (e.g., processed foods) for patients with history of hyperkalemia 2, 4
• Be aware of factors affecting potassium measurement including diurnal variation, sample type, and medication effects 2, 4

Medication Management and Drug Stewardship

Adjust all medication dosages according to kidney function. 1

• Drugs with narrow therapeutic windows need to be dosed according to the most accurate assessment of GFR, which may require direct measurement 2
• Recognize the risks of polypharmacy and consider deprescribing when appropriate 2
• Prefer non-vitamin K antagonist oral anticoagulants (NOACs) over vitamin K antagonists, with appropriate dose adjustments based on GFR 1

Monitoring and Risk Assessment

Use validated risk prediction equations incorporating eGFR and albuminuria to guide management intensity. 1

• A 2-year kidney failure risk >10% triggers multidisciplinary care and >40% initiates kidney replacement therapy preparation 1
• Assess risk factors regularly (every 3-6 months) 4
• Consider all people with CKD at increased risk for acute kidney injury (AKI) 2, 4
• Monitor for CKD progression using both blood and urine tests, with frequency guided by individual risk 4

Referral to Nephrology

Refer to nephrology when 5-year kidney failure risk is 3-5% or when eGFR <30 ml/min/1.73m² or albuminuria ≥300 mg per 24 hours. 1

• Patients at high risk of CKD progression (eGFR <30 ml/min/1.73m², albuminuria ≥300 mg per 24 hours, or rapid decline in eGFR) should be promptly referred 5

Symptom Management and Quality of Life

Regularly screen for symptoms using validated tools. 1, 4

• Screen for and treat depression, which affects approximately 26.5% of patients with CKD stages 1-4 1, 4
• Address pain using a stepwise approach, starting with non-pharmacological interventions and advancing to pharmacological therapy as needed 4
• Maximize health-related quality of life, physical function, capacity to work, and ability to socialize 1

Common Pitfalls to Avoid

• Do not withhold appropriate cardiovascular care based on CKD status - the level of care for ischemic heart disease should not be prejudiced by CKD 2
• Avoid NSAIDs due to nephrotoxicity risk 5
• Recognize that small fluctuations in GFR are common and do not necessarily indicate progression 4
• New evidence suggests that intravenous contrast does not carry large risks in people with CKD, and imaging studies should be performed based on clinical need 2