What is the management strategy for adults with chronic kidney disease (CKD) or acute kidney injury (AKI), including medication doses?

Management of Chronic Kidney Disease and Acute Kidney Injury in Adults

For adults with CKD, implement blood pressure control with ACE inhibitors or ARBs (especially when albuminuria ≥300 mg/24h), initiate SGLT2 inhibitors for renal protection, prescribe statins for cardiovascular risk reduction, and recognize that all CKD patients are at increased risk for AKI requiring vigilant monitoring. 1, 2

Blood Pressure Management Strategy

For CKD with Minimal Albuminuria (<30 mg/24h)

• Target BP: ≤140/90 mmHg using any BP-lowering drug class 1
• Start with standard antihypertensive agents based on comorbidities 1

For CKD with Albuminuria ≥30 mg/24h

• Target BP: ≤130/80 mmHg with more aggressive control 1
• Mandatory RAAS blockade when albuminuria exceeds 300 mg/24h 1

Specific Drug Selection and Dosing

ACE Inhibitors (choose one):

• Lisinopril: Start 10 mg daily, titrate to 40 mg daily
• Enalapril: Start 5 mg daily, titrate to 20 mg twice daily
• Ramipril: Start 2.5 mg daily, titrate to 10 mg daily

ARBs (choose one):

• Losartan: Start 50 mg daily, titrate to 100 mg daily
• Irbesartan: Start 150 mg daily, titrate to 300 mg daily
• Valsartan: Start 80 mg daily, titrate to 320 mg daily

Critical caveat: Do NOT combine ACE inhibitors with ARBs—evidence is insufficient to support dual RAAS blockade and may increase harm 1

SGLT2 Inhibitor Therapy

Canagliflozin dosing for CKD (with or without diabetes):

• 100 mg orally once daily before first meal for all CKD indications 3
• Can increase to 300 mg daily only if eGFR ≥60 mL/min/1.73 m² AND patient has diabetes requiring additional glycemic control 3
• Withhold 3 days before surgery or procedures with prolonged fasting 3
• SGLT2 inhibitors are first-line therapy for most CKD patients regardless of diabetes status 2

Cardiovascular Risk Reduction with Statins

For Patients ≥50 Years Old

• CKD stages G3a-G5 (eGFR <60): Statin or statin/ezetimibe combination mandatory 1
• CKD stages G1-G2 (eGFR ≥60): Statin therapy mandatory 1

For Patients 18-49 Years Old

• Initiate statin if ANY of the following present: 1
  • Known coronary disease (MI or revascularization)
  • Diabetes mellitus
  • Prior ischemic stroke
  • 10-year cardiovascular risk >10%

Specific Statin Dosing

High-intensity statins (maximize LDL reduction):

• Rosuvastatin: 5-10 mg daily (preferred in CKD stage 3B) 4
• Atorvastatin: 40-80 mg daily
• Simvastatin: 20-40 mg daily (avoid 80 mg dose)

Combination therapy:

• Add ezetimibe 10 mg daily if LDL goals not met with statin alone 1
• Consider PCSK-9 inhibitors for patients with indications 1

Lifestyle Interventions (Non-Negotiable Components)

• Sodium restriction: <2 g per day (approximately 5 g salt) 1
• Target BMI: 20-25 kg/m² through caloric restriction and exercise 1
• Complete smoking cessation (refer to cessation programs) 1, 2
• Exercise: 30 minutes, 5 times per week of moderate intensity 1, 2
• Mediterranean-style plant-based diet to reduce cardiovascular risk 1, 4, 2
• Limit alcohol, red meat, and high-fructose corn syrup 1, 4

Diabetes Management in CKD

• Target HbA1c: 7% to reduce proteinuria and slow progression 1
• SGLT2 inhibitors are first-line for glycemic control and renal protection 2, 3
• Consider GLP-1 receptor agonists per KDIGO Diabetes Guidelines 2

Management of CKD Complications

Hyperkalemia Management

• Implement individualized dietary and pharmacologic interventions through renal dietitian 1
• Limit bioavailable potassium foods (especially processed foods) in CKD G3-G5 with hyperkalemia history 1
• Do NOT discontinue RAAS inhibitors prematurely for mild hyperkalemia—use potassium binders instead 2

Hyperuricemia and Gout

For symptomatic hyperuricemia (gout):

• Xanthine oxidase inhibitors preferred over uricosuric agents 1
  • Allopurinol: Start 100 mg daily, titrate slowly based on renal function
  • Febuxostat: 40-80 mg daily (use with caution in cardiovascular disease)

For acute gout flares in CKD:

• Low-dose colchicine (0.6 mg once or twice daily) OR 1, 4
• Oral glucocorticoids (prednisone 20-40 mg daily for 5-7 days) OR 1, 4
• Intra-articular glucocorticoid injection for monoarticular disease 1, 4
• AVOID NSAIDs completely—they cause nephrotoxicity and AKI in CKD 1, 4

For asymptomatic hyperuricemia:

• Do NOT treat with uric acid-lowering agents—no benefit for CKD progression 1

Antiplatelet Therapy

• Low-dose aspirin 81 mg daily for secondary prevention in established cardiovascular disease 1
• Consider P2Y12 inhibitors (clopidogrel 75 mg daily) if aspirin intolerant 1

Acute Kidney Injury Prevention and Recognition

All CKD patients are at increased risk for AKI and require heightened vigilance 1, 5, 6

Key AKI Risk Factors in CKD Patients

• Advanced age, diabetes, decreased baseline GFR, and low serum albumin 7
• Nephrotoxic medications (NSAIDs, aminoglycosides, contrast agents) 5, 6
• Volume depletion, sepsis, and invasive procedures 6

AKI Prevention Strategies

• Assess volume status before initiating SGLT2 inhibitors and correct depletion 3
• Avoid all nephrotoxic drugs, particularly NSAIDs in CKD stage 3B or higher 4, 5
• Review all medications for appropriate CKD dosing 2
• Withhold RAAS inhibitors and SGLT2 inhibitors during acute illness with volume depletion 3

Monitoring for AKI-to-CKD Progression

• AKI accelerates CKD progression, especially dialysis-requiring AKI 8, 7, 9
• Monitor serum creatinine and potassium every 3-6 months in stable CKD 2
• Increase monitoring frequency after any AKI episode (weekly initially, then monthly) 8, 7
• Progression defined as: eGFR decline ≥25% AND change in GFR category 1

Monitoring Schedule by CKD Stage

CKD G1-G2 (eGFR ≥60):

• Monitor every 3-6 months if albuminuria present 2
• Annual monitoring if no albuminuria 1

CKD G3a-G3b (eGFR 30-59):

• Monitor every 3-6 months 1

CKD G4-G5 (eGFR <30):

• Monitor every 1-3 months 1

Critical Pitfalls to Avoid

• Never use NSAIDs in CKD stage 3B or higher—this significantly increases AKI risk and accelerates progression 1, 4, 5
• Do not combine ACE inhibitors with ARBs—no evidence of benefit and potential for harm 1
• Do not discontinue RAAS inhibitors for creatinine elevation up to 30%—this is expected and acceptable 2
• Do not delay statin therapy—cardiovascular disease is the leading cause of death in CKD 1, 4
• Do not overlook SGLT2 inhibitor initiation—these provide significant renal protection beyond glycemic control 2, 3
• Do not ignore AKI episodes—each episode accelerates CKD progression and requires intensified monitoring 8, 7, 9