Management Strategies for Chronic Kidney Disease
Core Pharmacologic Therapy
Initiate SGLT2 inhibitors as first-line therapy for most CKD patients and continue until dialysis or transplant, representing the most significant advancement in CKD management with robust evidence for delaying progression and reducing cardiovascular complications 1.
Prescribe RAS inhibition (ACE inhibitor or ARB) at maximum tolerated dose when hypertension or albuminuria is present, titrating to the highest approved dose that is tolerated to maximize kidney protection 1.
Administer statin therapy (moderate to high-intensity) or statin/ezetimibe combination for all adults ≥50 years with eGFR <60 mL/min/1.73 m² (CKD G3a-G5), choosing regimens that maximize absolute LDL cholesterol reduction 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.
Blood Pressure Management
Target systolic blood pressure <120 mmHg for most CKD patients, representing a more aggressive target than previous guidelines and supported by cardiovascular outcome data 1.
For patients without albuminuria (<30 mg/24h), target blood pressure <140/90 mmHg 3, 2.
For patients with albuminuria 30-300 mg/24h, target blood pressure <130/80 mmHg 3, 2.
For patients with albuminuria >300 mg/24h, target blood pressure <130/80 mmHg 3, 2.
Use ACE inhibitor or ARB as first-line antihypertensive therapy when albuminuria ≥30 mg/24h is present, given the proven kidney protective effects 3, 1.
Add dihydropyridine calcium channel blockers and/or diuretics as needed to achieve blood pressure targets 4.
Monitor for postural hypotension regularly when treating CKD patients with BP-lowering drugs 3.
Lifestyle Modifications
Advise patients to undertake moderate-intensity physical activity for at least 150 minutes per week, adjusted to their cardiovascular and physical tolerance 3, 2, 1.
For patients at higher risk of falls, provide specific advice on the intensity of physical activity (low, moderate, or vigorous) and the type of exercises (aerobic vs. resistance, or both) 3.
Encourage weight loss for patients with obesity and CKD through diet, physical activity, and behavioral therapy 2, 4.
Advise smoking cessation as tobacco use accelerates CKD progression 4.
Dietary Management
Advise patients to adopt healthy, diverse diets with higher consumption of plant-based foods compared to animal-based foods and lower consumption of ultraprocessed foods 3, 2, 1.
Maintain protein intake at 0.8 g/kg body weight/day in adults with CKD G3-G5 3, 2, 1.
Avoid high protein intake (>1.3 g/kg body weight/day) in adults with CKD at risk of progression 3, 1.
In adults with CKD who are willing and able, and who are at risk of kidney failure, consider prescribing, under close supervision, a very low-protein diet (0.3-0.4 g/kg body weight/day) 3.
Limit sodium intake to <2 g per day (equivalent to <90 mmol/day or <5 g sodium chloride/day) 2.
Use renal dietitians or accredited nutrition providers to educate patients about dietary adaptations regarding sodium, phosphorus, potassium, and protein intake, tailored to their individual needs 3, 2.
Glycemic Control in Diabetic CKD
Target hemoglobin A1c of approximately 7% 2, 4.
Use metformin as first-line therapy when eGFR ≥30 ml/min/1.73m² 2, 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.
Cardiovascular Risk Reduction
Prescribe oral low-dose aspirin for secondary prevention in people with CKD and established ischemic cardiovascular disease 1.
Consider other antiplatelet therapy (e.g., P2Y12 inhibitors) when there is aspirin intolerance 1.
Use non-vitamin K antagonist oral anticoagulants (NOACs) in preference to vitamin K antagonists (e.g., warfarin) for thromboprophylaxis in atrial fibrillation in people with CKD G1-G4 1.
Management of Metabolic Complications
Provide pharmacological treatment with or without dietary intervention when serum bicarbonate <18 mmol/L 2, 4.
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.
Implement an individualized approach for patients with CKD G3-G5 and hyperkalemia, including dietary and pharmacologic interventions 4.
Limit intake of foods rich in bioavailable potassium (e.g., processed foods) for patients with history of hyperkalemia 4.
Anemia Management
Initiate erythropoiesis-stimulating agents (ESAs) only when hemoglobin is <10 g/dL, using the lowest dose sufficient to reduce the need for RBC transfusions 5.
For adult patients with CKD on dialysis, the recommended starting dose is 50 to 100 Units/kg 3 times weekly intravenously or subcutaneously 5.
For adult patients with CKD not on dialysis, consider initiating treatment only when hemoglobin is <10 g/dL and the rate of hemoglobin decline indicates likelihood of requiring RBC transfusion 5.
Evaluate iron status before and during treatment; administer supplemental iron when serum ferritin is <100 mcg/L or when serum transferrin saturation is <20% 5.
Monitor hemoglobin weekly until stable after initiating therapy or dose adjustment, then monitor at least monthly 5.
If hemoglobin rises rapidly (>1 g/dL in any 2-week period), reduce the ESA dose by 25% or more 5.
Do not target hemoglobin levels >11 g/dL, as patients experience greater risks for death, serious adverse cardiovascular reactions, and stroke 5.
Risk Assessment and Monitoring
Use validated risk prediction equations incorporating eGFR and albuminuria to guide management intensity, with a 2-year kidney failure risk >10% triggering multidisciplinary care and >40% initiating kidney replacement therapy preparation 2.
For cardiovascular risk assessment, apply externally validated models developed specifically for CKD populations that incorporate both eGFR and albuminuria 2.
Test people at risk for CKD using both urine albumin measurement and assessment of glomerular filtration rate (GFR) 1.
Assess risk factors regularly (every 3-6 months) 4.
Monitor for CKD progression using both blood and urine tests, with frequency guided by individual risk 4.
Medication Management
Adjust all medication dosages according to kidney function 2.
Consider GFR when dosing medications cleared by the kidneys 1.
For most clinical settings, validated eGFR equations using serum creatinine are appropriate for drug dosing 1.
Perform thorough medication review periodically and at transitions of care to assess adherence, continued indication, and potential drug interactions 1.
Referral to Specialist Kidney Care
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 2.
Refer adults with CKD to specialist kidney care services when they have ACR ≥30 mg/g (3 mg/mmol) or PCR ≥200 mg/g (20 mg/mmol) 1.
Refer adults with CKD to specialist kidney care services when they have persistent hematuria 1.
Refer adults with CKD to specialist kidney care services when they have any sustained decrease in eGFR 1.
Symptom Management and Quality of Life
Regularly screen for symptoms using validated tools 2, 4.
Screen for and treat depression, which affects approximately 26.5% of patients with CKD stages 1-4 2, 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 3, 2.
Special Populations
For children with CKD, encourage physical activity aiming for WHO-advised levels (≥60 minutes daily) and achievement of healthy weight 3, 1.
Do not restrict protein intake in children with CKD due to the risk of growth impairment, with target protein and energy intake at the upper end of the normal range for healthy children to promote optimal growth 1.
In older adults with underlying conditions such as frailty and sarcopenia, consider higher protein and calorie dietary targets 1.
Critical Pitfalls to Avoid
Never prescribe NSAIDs in CKD due to nephrotoxicity risk and potential for acute kidney injury—use low-dose colchicine or glucocorticoids instead for inflammatory conditions like acute gout 1.
Do NOT use agents to lower serum uric acid in CKD patients with asymptomatic hyperuricemia to delay CKD progression 1.
Do not discontinue RAS inhibitors due to modest increases in serum creatinine or potassium unless there are specific contraindications 1.
In pregnant women, lactating women, neonates, and infants use only single-dose vials (the benzyl alcohol-free formulation) of erythropoietin 5.