What is the management plan for a patient with Chronic Kidney Disease (CKD) stage 5, Diabetes Mellitus (DM), and Hypertension (HTN)?

Management of CKD Stage 5 with Diabetes Mellitus and Hypertension

For a patient with CKD stage 5, diabetes, and hypertension, immediately initiate an SGLT2 inhibitor (if eGFR ≥20 mL/min/1.73 m²), continue ACE inhibitor or ARB therapy (if already established with albuminuria), target blood pressure <140/90 mmHg, add statin therapy, and prepare for renal replacement therapy while implementing comprehensive lifestyle modifications. 1

Pharmacologic Management Strategy

SGLT2 Inhibitors - First Priority

• Start an SGLT2 inhibitor immediately if eGFR ≥20 mL/min/1.73 m², regardless of current glycemic control. 1
• Continue SGLT2 inhibitors until dialysis or transplantation is initiated, as kidney and cardiovascular benefits persist even at very low eGFR levels. 1
• Before initiating, assess hypoglycemia risk, particularly if the patient is on insulin or sulfonylureas, and consider dose reduction of these agents. 1
• SGLT2 inhibitors provide kidney protection, cardiovascular benefits, and reduce heart failure hospitalizations independent of glucose-lowering effects. 1

RAS Blockade - Critical for Albuminuria

• Continue ACE inhibitor or ARB therapy if the patient has albuminuria and was previously tolerating these agents. 2
• If not already on therapy and albuminuria is present with hypertension, initiate ACE inhibitor or ARB and titrate to the highest tolerated dose. 2
• Monitor serum creatinine and potassium within 2-4 weeks of any dose adjustment. 2, 1
• Continue therapy unless creatinine rises >30% within 4 weeks—this degree of increase warrants evaluation for acute kidney injury, volume depletion, or renal artery stenosis. 2, 1
• Do not immediately discontinue for hyperkalemia—first attempt management through dietary modification, diuretics, sodium bicarbonate, or GI cation exchangers. 1

Metformin - Discontinue at This Stage

• Metformin must be discontinued when eGFR falls below 30 mL/min/1.73 m² due to lactic acidosis risk. 1

Additional Glucose Management

• Add a GLP-1 receptor agonist if glycemic targets are not met with SGLT2 inhibitors or if SGLT2 inhibitors cannot be used. 1
• Consider adding finerenone (nonsteroidal mineralocorticoid receptor antagonist) if persistent albuminuria ≥30 mg/g despite first-line therapy and potassium levels are normal. 1
• Target HbA1c between <6.5% and <8.0%, individualized based on hypoglycemia risk, life expectancy, comorbidities, and patient preferences. 1
• Check HbA1c every 3 months when therapy changes or targets are not met, and at least twice yearly in stable patients. 1

Blood Pressure Management

Target Blood Pressure

• Target blood pressure <140/90 mmHg for CKD stage 5. 3
• Exercise caution with intensive BP lowering in advanced CKD, as the risk of acute kidney injury is substantially higher than in earlier CKD stages. 3
• Be aware that intensive BP lowering may accelerate the need for kidney replacement therapy in some patients. 3
• Among older individuals, diastolic BP is often low due to increased arterial stiffness, making aggressive systolic BP lowering potentially problematic. 3

Antihypertensive Medication Selection

• ACE inhibitors or ARBs remain preferred agents if albuminuria is present, as they reduce progression to end-stage renal disease. 3, 4
• Calcium channel blockers are a viable option for BP reduction, particularly in patients who cannot tolerate ACE inhibitors or ARBs. 3
• Loop diuretics are effective for volume control in advanced CKD and should be used judiciously to avoid dehydration and electrolyte imbalances. 3
• Avoid dual RAAS blockade (combining ACE inhibitor and ARB) as this increases adverse events without additional benefit. 3

Critical Monitoring Points

• Further GFR decline beyond the initial 30% after starting ACE inhibitors/ARBs should be investigated for other causes such as volume contraction, nephrotoxic agents, or renovascular disease. 3
• Masked hypertension may occur in up to 30% of patients with CKD and is associated with worse outcomes—consider home or ambulatory BP monitoring. 3

Cardiovascular Risk Reduction

Lipid Management

• Initiate statin therapy in all patients with diabetes and CKD. 1

Antiplatelet Therapy

• Use aspirin lifelong for secondary prevention in those with established cardiovascular disease. 2
• Consider aspirin for primary prevention among high-risk individuals, balanced against increased bleeding risk including thrombocytopathy at low GFR. 2
• Use dual antiplatelet therapy in patients after acute coronary syndrome or percutaneous coronary intervention per clinical guidelines. 2

Lifestyle Modifications

Dietary Interventions

• Limit protein intake to 0.8 g/kg/day for patients with diabetes and CKD not on dialysis. 1
• Restrict sodium intake to <2 g/day (<90 mmol/day or <5 g sodium chloride/day). 1

Physical Activity and Smoking

• Advise moderate-intensity physical activity for at least 150 minutes per week, or to a level compatible with cardiovascular and physical tolerance. 1
• Strongly recommend tobacco cessation for all patients who use tobacco products. 1

Comprehensive Complication Screening

Diabetes-Related Complications

• Screen regularly for retinopathy, neuropathy, and foot complications. 2
• Perform comprehensive foot examination including visual inspection, Semmes-Weinstein monofilament testing, 128-Hz tuning fork for vibratory sensation, and pedal pulse evaluation annually. 2
• Refer to foot-care specialists for annual examinations and preventive care given high risk of ulcers and amputations. 2

Cardiovascular Screening

• Monitor for ischemia, arrhythmia, and heart failure risk. 2

Preparation for Renal Replacement Therapy

• As CKD stage 5 approaches end-stage kidney disease, management of anemia, bone and mineral disorders, fluid and electrolyte disturbances, and preparation for dialysis or transplantation become increasingly dominant. 2
• Structured, monitored, individualized patient education regarding dialysis options and transplantation should be provided. 2

Common Pitfalls to Avoid

• Do not discontinue ACE inhibitors/ARBs prematurely for mild hyperkalemia—attempt potassium management strategies first. 1
• Do not combine ACE inhibitors with ARBs. 3
• Do not continue metformin at eGFR <30 mL/min/1.73 m². 1
• Do not pursue overly aggressive BP targets (<130/80 mmHg) in CKD stage 5 without careful consideration of AKI risk. 3
• Discontinue ACE inhibitors/ARBs in women considering pregnancy or who become pregnant. 2