What is the primary management approach for a patient with Chronic Kidney Disease (CKD)?

Primary Management of Chronic Kidney Disease

The primary management approach for CKD centers on a comprehensive cardiorenal risk reduction strategy built upon four foundational pillars: SGLT2 inhibitors for patients with type 2 diabetes, RAS blockade for those with albuminuria and hypertension, statin therapy for cardiovascular protection, and lifestyle modifications including dietary sodium restriction and regular physical activity. 1

Core Pharmacologic Interventions

SGLT2 Inhibitors (Type 2 Diabetes)

• Initiate an SGLT2 inhibitor immediately in all patients with type 2 diabetes and CKD when eGFR ≥20 mL/min/1.73 m², regardless of glycemic control status or albuminuria level 1, 2
• Continue SGLT2 inhibitors until dialysis or transplantation is initiated, as they provide kidney and cardiovascular protection independent of glucose-lowering effects 1
• Expect an initial eGFR decline of 3-5 mL/min/1.73 m² within 2-4 weeks—this is a hemodynamic effect and not a reason to discontinue therapy 2
• Monitor for volume depletion, hypotension, and genital mycotic infections during the first month 2

RAS Blockade

• Initiate an ACE inhibitor or ARB in all patients with diabetes, hypertension, and albuminuria, titrating to the highest approved tolerated dose 1
• Monitor serum creatinine and potassium within 2-4 weeks of initiation or dose adjustment 2
• Accept up to 30% creatinine rise if stable, as this reflects beneficial hemodynamic changes 2
• Target blood pressure <130/80 mmHg in patients with CKD and diabetes 2

Statin Therapy

• Prescribe a statin or statin/ezetimibe combination for all adults ≥50 years with eGFR <60 mL/min/1.73 m² (CKD stages G3a-G5) 1
• For adults ≥50 years with eGFR ≥60 mL/min/1.73 m² (stages G1-G2), prescribe a statin 1
• For adults 18-49 years with CKD, prescribe a statin if they have coronary disease, diabetes, prior ischemic stroke, or 10-year cardiovascular risk >10% 1
• Choose statin-based regimens that maximize absolute LDL cholesterol reduction 1

Glycemic Management (Type 2 Diabetes)

• Continue metformin when eGFR ≥30 mL/min/1.73 m²; discontinue only if eGFR falls below 30 mL/min/1.73 m² 2, 3
• For patients with eGFR 30-44 mL/min/1.73 m², reduce metformin dose to 1000 mg daily 3
• Add a GLP-1 receptor agonist (semaglutide or dulaglutide) if HbA1c remains >7.0% after 3 months on metformin plus SGLT2 inhibitor 2
• Individualize glycemic targets between <6.5% and <8% based on hypoglycemia risk, with more intensive targets possible using medications not associated with hypoglycemia 1

Lifestyle Interventions

Dietary Modifications

• Prescribe dietary protein intake of exactly 0.8 g/kg body weight per day for patients not on dialysis 1, 2
• Restrict sodium intake to <2 g/day (or <5 g sodium chloride per day) to reduce blood pressure and slow CKD progression 1, 2
• Recommend a Mediterranean-style, plant-based diet high in vegetables, fruits, whole grains, fiber, legumes, unsaturated fats, and nuts, while limiting processed meats, refined carbohydrates, and sweetened beverages 1, 2
• For patients on peritoneal dialysis, increase protein intake to 1.0-1.2 g/kg to offset catabolism 1

Physical Activity

• Prescribe moderate-intensity physical activity for a cumulative duration of at least 150 minutes per week, or to a level compatible with cardiovascular and physical tolerance 1, 2

Smoking and Weight Management

• Advise complete tobacco cessation 1
• Address obesity through dietary modifications and physical activity 1

Medication Safety and Avoidance

Nephrotoxins to Eliminate

• Stop all NSAIDs immediately, as they accelerate kidney decline and increase cardiovascular risk 2, 4
• Discontinue proton pump inhibitors unless absolutely necessary 2
• Review and eliminate all dietary supplements and herbal remedies, as many contain nephrotoxic compounds 2

Antiplatelet Therapy

• Use aspirin lifelong for secondary prevention in patients with established cardiovascular disease 1
• Consider aspirin for primary prevention in high-risk individuals, balanced against bleeding risk 1

Monitoring Schedule

Laboratory Assessments

• Reassess eGFR, serum creatinine, potassium, bicarbonate, and urine albumin-to-creatinine ratio every 3 months 2
• Monitor HbA1c every 3 months until stable at target 2
• Screen for CKD complications including hyperkalemia, metabolic acidosis, hyperphosphatemia, vitamin D deficiency, secondary hyperparathyroidism, and anemia 5

Blood Pressure Monitoring

• Measure blood pressure at every clinical encounter 2
• Use home blood pressure monitoring when available to guide treatment adjustments 1

Nephrology Referral Criteria

Refer to nephrology immediately for patients with: 5

• eGFR <30 mL/min/1.73 m² (CKD stages 4-5)
• Albuminuria ≥300 mg per 24 hours (or albumin-to-creatinine ratio ≥300 mg/g)
• Rapid decline in eGFR (>5 mL/min/1.73 m² per year)
• Uncertain etiology of CKD requiring diagnostic evaluation 6

Team-Based Care Coordination

• Establish multidisciplinary care involving primary care, nephrology, endocrinology/diabetes educator, and clinical pharmacist 2
• Provide structured, individualized diabetes self-management education focusing on medication adherence, dietary modifications, blood glucose monitoring, and recognition of complications 1, 2
• Perform thorough medication reviews periodically and at all care transitions to assess adherence, continued indication, and potential drug interactions 4

Common Pitfalls to Avoid

• Do not discontinue SGLT2 inhibitors due to initial eGFR decline—this hemodynamic effect is expected and beneficial 2
• Do not withhold RAS inhibitors due to modest creatinine elevation (<30% increase)—this reflects appropriate hemodynamic changes 2
• Do not restrict protein intake below 0.8 g/kg/day—lower intake has not been shown to improve outcomes and may cause malnutrition 1
• Do not continue metformin when eGFR falls below 30 mL/min/1.73 m²—this increases lactic acidosis risk 3
• Do not delay nephrology referral in advanced CKD (eGFR <30)—early specialist involvement improves outcomes and preparation for kidney replacement therapy 2, 5