Chronic Kidney Disease Management Smart Phrase
Initial Assessment and Monitoring
All CKD patients require annual screening with spot urinary albumin-to-creatinine ratio (UACR) and estimated glomerular filtration rate (eGFR), with monitoring frequency increasing to 1-4 times yearly based on disease stage and albuminuria severity. 1
Monitoring Schedule by CKD Stage:
- eGFR ≥60 with normal albuminuria: Annual monitoring 1
- eGFR 45-59 or UACR 30-299 mg/g: Every 6 months 1
- eGFR 30-44 or UACR ≥300 mg/g: Every 4 months 1
- eGFR <30: Every 3 months 1
Laboratory Monitoring Every 3-5 Months:
- Serum creatinine, eGFR, potassium, bicarbonate 2
- UACR 2
- Hemoglobin, phosphorus, calcium, PTH (as CKD advances) 3
- More frequent monitoring required after any medication changes affecting renin-angiotensin system 2
Pharmacological Management Algorithm
Step 1: SGLT2 Inhibitors (MANDATORY FIRST-LINE)
Initiate SGLT2 inhibitor immediately for all CKD patients with eGFR ≥20 mL/min/1.73 m², regardless of diabetes status. 2, 3
- Dapagliflozin 10 mg daily OR Canagliflozin 100 mg daily 3
- Continue even as eGFR declines below 20 until dialysis or transplantation 3
- For type 2 diabetes with diabetic kidney disease and UACR ≥200 mg/g: Class A recommendation 1
Step 2: Renin-Angiotensin System Blockade
Initiate ACE inhibitor or ARB for all patients with albuminuria ≥30 mg/g and hypertension, titrating to maximum tolerated dose. 1
Specific Indications:
- UACR 30-299 mg/g + hypertension: ACE inhibitor or ARB recommended 1
- UACR ≥300 mg/g and/or eGFR <60: ACE inhibitor or ARB strongly recommended 1
- Target BP <130/80 mmHg for patients with albuminuria ≥30 mg/g 2, 3
- Target BP <140/90 mmHg for CKD without significant albuminuria 1
Monitoring RAS Blockade:
- Do NOT discontinue for serum creatinine increases ≤30% in absence of volume depletion 1
- Monitor serum creatinine and potassium periodically 1
Step 3: Statin Therapy
Prescribe moderate-to-high intensity statin for all CKD patients ≥50 years old. 3
- Atorvastatin 40-80 mg daily OR Rosuvastatin 20-40 mg daily 3
Step 4: Additional Kidney Protection (When Indicated)
For patients unable to use SGLT2 inhibitors or requiring additional protection, add finerenone (nonsteroidal mineralocorticoid receptor antagonist). 1, 3
- Indicated for increased cardiovascular risk or CKD progression risk 1
Step 5: Glycemic Control (Diabetic CKD)
- Continue metformin if eGFR ≥30 mL/min/1.73 m² 2
- Discontinue metformin if eGFR <30 mL/min/1.73 m² 2, 3
- Add GLP-1 receptor agonist for additional cardiorenal protection 2
- Target HbA1c optimization to reduce CKD progression 1
Lifestyle and Dietary Modifications
Dietary Protein Restriction
Prescribe protein intake of exactly 0.8 g/kg body weight/day for CKD G3-G5. 1, 2
- Avoid high protein intake >1.3 g/kg/day in patients at risk of progression 1
- Consider very low-protein diet (0.3-0.4 g/kg/day) under close supervision for patients at risk of kidney failure 1
- Higher protein intake for dialysis patients due to malnutrition risk 1
Sodium Restriction
Limit sodium intake to <2,300 mg/day (or <2 g/day for stricter control). 2, 3
Dietary Pattern
Recommend Mediterranean-style, plant-based diet with higher consumption of plant-based foods compared to animal-based foods. 1, 2
- Increase fruits, vegetables, whole grains, legumes 2
- Limit red meat and processed meats 2
- Lower consumption of ultraprocessed foods 1
Physical Activity
Prescribe moderate-intensity physical activity for cumulative duration of at least 150 minutes per week. 1, 2
- Tailor to cardiovascular tolerance and frailty level 1
- Avoid sedentary behavior 1
- For children: ≥60 minutes daily per WHO guidelines 1
Weight Management
Target BMI 20-25 kg/m² through structured weight management program. 3
Smoking Cessation
Mandate complete tobacco cessation with referral to smoking cessation programs. 1, 2
Management of CKD Complications
Anemia Management
Monitor hemoglobin regularly; treat with iron supplementation before or with erythropoiesis-stimulating agents. 3
Metabolic Acidosis
Initiate oral alkali supplementation when present. 2
CKD-Mineral and Bone Disorder
Monitor and treat hyperphosphatemia, vitamin D deficiency, and secondary hyperparathyroidism. 1, 4
Hyperkalemia and Electrolyte Disorders
Monitor and manage potassium disorders and other electrolyte abnormalities. 1
Cardiovascular Disease Prevention
Secondary Prevention
Prescribe aspirin 81 mg daily for lifelong secondary prevention in CKD patients with established cardiovascular disease. 1, 3
- Dual antiplatelet therapy after acute coronary syndrome or percutaneous coronary intervention per clinical guidelines 1
Primary Prevention
Consider aspirin for primary prevention in high-risk individuals, balanced against bleeding risk. 1
Medications to AVOID in CKD
Absolute Contraindications:
- NSAIDs: Discontinue immediately due to acute kidney injury risk 2, 3, 4
- Metformin when eGFR <30 mL/min/1.73 m²: Risk of lactic acidosis 2, 3
- Sulfonylureas: Increased hypoglycemia risk 3
Use with Extreme Caution:
- Proton pump inhibitors: Avoid unless absolutely necessary 2
- Iodinated contrast and gadolinium-based agents: Use extreme caution 2
- Dietary/herbal remedies: Review and limit due to nephrotoxic compounds 2
Medication Adjustments:
Adjust all renally-cleared medications for eGFR, including many antibiotics and oral hypoglycemic agents. 2, 4
Nephrology Referral Criteria
Refer immediately to nephrology when ANY of the following criteria are met: 2, 3, 4
- eGFR <30 mL/min/1.73 m² (CKD G4-G5) 3, 4
- eGFR <45 mL/min/1.73 m² with significant albuminuria 2
- UACR ≥300 mg/g 4
- Rapid decline in eGFR (>5 mL/min/1.73 m² per year) 4
- Persistent electrolyte abnormalities despite treatment 3
- Uncontrolled hypertension despite multiple agents 3
Delaying nephrology referral for advanced CKD leads to poor outcomes. 2
Target for Albuminuria Reduction
Achieve ≥30% reduction in UACR to slow CKD progression in patients with UACR ≥300 mg/g. 1