What are the management steps for a patient with Chronic Kidney Disease (CKD), including those with comorbid conditions such as hypertension, diabetes, and cardiovascular disease?

Management of Chronic Kidney Disease

All CKD patients require a systematic approach addressing five core domains: cardiovascular risk reduction, blood pressure control, glycemic management (if diabetic), monitoring for CKD complications, and timely nephrology referral. 1

Initial Assessment and Staging

• Stage CKD using both eGFR and albuminuria to determine prognosis and guide treatment intensity 2
• Measure serum creatinine, calculate eGFR, and obtain urine albumin-to-creatinine ratio at baseline 2, 3
• Screen annually for diabetic patients with type 1 diabetes ≥5 years duration, all type 2 diabetics, and anyone with hypertension 2
• Obtain detailed history focusing on diabetes duration, hypertension, cardiovascular disease, nephrotoxin exposure (NSAIDs, contrast agents), and family history of kidney disease 2
• Perform laboratory evaluation including complete metabolic panel, CBC, lipid panel, hemoglobin A1c (if diabetic), and urinalysis 2

Blood Pressure Management

Target systolic BP <130 mmHg in all CKD patients with albuminuria ≥30 mg/g; target <140/90 mmHg if albuminuria <30 mg/g. 2, 4

• Initiate ACE inhibitor or ARB as first-line therapy for all patients with albuminuria ≥30 mg/g, titrating to maximum tolerated doses 2, 1
• For albuminuria ≥300 mg/g, ACE inhibitor or ARB use is a strong (1B) recommendation 2
• Monitor serum creatinine and potassium within 2-4 weeks after starting or dose escalation 2, 1
• Continue therapy unless creatinine rises >30% within 4 weeks—this threshold warrants evaluation for acute kidney injury, volume depletion, or renal artery stenosis 1
• Add long-acting dihydropyridine calcium channel blocker as second agent if BP remains uncontrolled 4
• Never combine ACE inhibitors with ARBs—this increases adverse events (hyperkalemia, AKI) without additional benefit 2
• Restrict sodium intake to <2 g/day to optimize antihypertensive effectiveness 2, 1

Diabetic CKD Management

Initiate SGLT2 inhibitor immediately when eGFR ≥20 mL/min/1.73 m², regardless of glycemic control, as this provides kidney protection and cardiovascular benefits independent of glucose lowering. 1

• Continue SGLT2 inhibitors until dialysis or transplantation, even as eGFR declines 1
• Add metformin when eGFR ≥30 mL/min/1.73 m² for additional glycemic control 1
• Reduce metformin to 1000 mg daily when eGFR 30-44 mL/min/1.73 m² 1
• Discontinue metformin when eGFR <30 mL/min/1.73 m² due to lactic acidosis risk 1
• Add GLP-1 receptor agonist if glycemic targets unmet or if SGLT2 inhibitors/metformin cannot be used 2, 1
• Consider finerenone (nonsteroidal mineralocorticoid receptor antagonist) for persistent albuminuria ≥30 mg/g despite first-line therapy and normal potassium 2, 1
• Target HbA1c between 6.5-8.0%, individualized based on hypoglycemia risk, life expectancy, and comorbidities 1
• Check HbA1c every 3 months when adjusting therapy, at least twice yearly when stable 1
• Limit dietary protein to 0.8 g/kg/day for non-dialysis CKD patients 2, 1

Cardiovascular Risk Reduction

Initiate statin therapy in all CKD patients with diabetes, targeting LDL-C <100 mg/dL (consider <70 mg/dL for very high risk). 2, 1

• Treat all diabetic CKD patients stages 1-4 with statins when LDL-C >100 mg/dL 2
• Do not initiate statins in type 2 diabetics on maintenance hemodialysis without specific cardiovascular indication 2
• Obtain 12-lead ECG to assess for left ventricular hypertrophy and arrhythmias 4
• Consider echocardiography if ECG abnormal or cardiac symptoms present 4
• Recommend tobacco cessation for all tobacco users 1
• Advise moderate-intensity physical activity for ≥150 minutes weekly, compatible with cardiovascular tolerance 1

Monitoring for CKD Complications

Begin monitoring for anemia, bone disease, metabolic acidosis, and hyperkalemia when eGFR <60 mL/min/1.73 m² (Stage 3). 2

• Monitor frequency based on GFR and albuminuria categories—higher risk requires more frequent assessment 2
• Check serum creatinine, eGFR, and urine albumin-to-creatinine ratio at least annually for moderate-to-severe CKD 4
• For eGFR <60 mL/min/1.73 m² or GFR decline ≥4 mL/min/1.73 m²/year, monitor every 1-6 months 2
• Assess for hyperkalemia, particularly in patients on ACE inhibitors/ARBs—attempt dietary modification, diuretics, sodium bicarbonate, or GI cation exchangers before discontinuing RAAS blockade 1
• Evaluate for anemia, secondary hyperparathyroidism, metabolic bone disease, and electrolyte disturbances as eGFR declines 2, 3
• Recognize all CKD patients are at increased risk for acute kidney injury—avoid nephrotoxins (NSAIDs, aminoglycosides, IV contrast) and monitor during volume depletion 2, 3

Nephrology Referral

Refer to nephrologist when eGFR <30 mL/min/1.73 m² (Stage 4), or earlier if uncertainty about etiology, difficult management issues, or rapid progression. 2, 4

• Specific indications include: eGFR <30 mL/min/1.73 m², albuminuria ≥300 mg/g despite treatment, rapidly declining kidney function, resistant hypertension, or electrolyte disturbances 2, 3
• Early referral (Stage 4) reduces cost, improves quality of care, and delays dialysis 2
• Begin preparation for kidney replacement therapy during Stage 4, well before uremic symptoms develop 2
• If monoclonal immunoglobulin detected, refer for evaluation of multiple myeloma or monoclonal gammopathy of renal significance 4

Medication Safety

• Adjust drug dosing based on eGFR for renally cleared medications (many antibiotics, oral hypoglycemics) 3
• Avoid NSAIDs and other nephrotoxins 3, 5
• Review all medications for appropriate dosing and potential nephrotoxicity at each visit 5