What is the best approach to manage a patient with chronic kidney disease and medical renal disease, particularly in terms of medication and lifestyle modifications to slow disease progression?

Management of Chronic Kidney Disease and Medical Renal Disease

For patients with CKD, initiate an ACE inhibitor or ARB titrated to maximum tolerated dose if albuminuria ≥30 mg/g is present with hypertension, add an SGLT2 inhibitor for all diabetic patients with eGFR ≥20 mL/min/1.73 m², target blood pressure ≤130/80 mmHg when albuminuria is present, and implement sodium restriction to <2 g/day with protein intake limited to 0.8 g/kg/day. 1, 2

Blood Pressure Management Strategy

Target blood pressure ≤130/80 mmHg for all patients with albuminuria ≥30 mg/24 hours. 1, 2, 3 For patients without significant albuminuria (<30 mg/24 hours), target ≤140/90 mmHg. 1, 2

First-Line Antihypertensive Selection

• Use ACE inhibitors or ARBs as first-line therapy when albuminuria ≥30 mg/g is present, regardless of diabetes status. 1, 3
• For albuminuria ≥300 mg/g, ACE inhibitor or ARB therapy is mandatory to slow progression and reduce cardiovascular events. 1, 2
• Titrate to the maximum approved dose that is tolerated, not just to blood pressure targets. 1
• Monitor serum creatinine and potassium within 2-4 weeks of initiation or dose adjustment. 1, 4
• Accept up to 30% increase in serum creatinine if it stabilizes—this is an expected hemodynamic effect and not a reason to discontinue. 3, 4

Critical Medication Warnings

Never combine ACE inhibitors with ARBs—this combination is harmful and increases adverse events without additional benefit. 1

For patients who develop cough on ACE inhibitors, switch to an ARB. 1 For those with hyperkalemia, implement potassium restriction and consider potassium binders rather than discontinuing RAAS blockade. 1

SGLT2 Inhibitor Therapy

For all patients with type 2 diabetes and CKD with eGFR ≥20 mL/min/1.73 m², initiate an SGLT2 inhibitor immediately, independent of glycemic control status. 1, 2, 4 This is foundational therapy that reduces CKD progression and cardiovascular events. 1, 4

• Start empagliflozin 10 mg daily or equivalent SGLT2 inhibitor. 4
• Expect an initial eGFR decline of 3-5 mL/min/1.73 m² within 2-4 weeks—this is hemodynamic and not a reason to stop. 4
• Monitor for volume depletion, hypotension, and genital mycotic infections during the first month. 4
• Continue SGLT2 inhibitors until dialysis or transplantation, even as eGFR declines to 20 mL/min/1.73 m². 1, 2

Glycemic Control for Diabetic CKD

Target HbA1c approximately 7% to reduce risk and slow CKD progression. 1, 2, 4

• Continue metformin when eGFR ≥30 mL/min/1.73 m²; discontinue only if eGFR falls below 30. 2, 4
• Add a GLP-1 receptor agonist (semaglutide or dulaglutide) if HbA1c remains >7% after 3 months on metformin plus SGLT2 inhibitor, as this provides additional cardiovascular and kidney benefits. 4

Lifestyle and Dietary Modifications

Restrict dietary sodium to <2 g per day to control blood pressure and reduce proteinuria. 1, 2, 3, 4

Limit protein intake to exactly 0.8 g/kg body weight per day for patients with CKD stage 3 or higher. 1, 2, 3, 4 Do not restrict protein in patients who are cachexic, sarcopenic, or undernourished. 1

Prescribe moderate-intensity physical activity for 150 minutes weekly (30 minutes, 5 times per week). 1, 2, 3, 4

Advise complete tobacco cessation for all patients with CKD. 1, 3

Target a healthy BMI of 20-25 kg/m² through weight management. 1, 3

Recommend a Mediterranean-style, plant-based diet high in vegetables, fruits, whole grains, legumes, and unsaturated fats, while limiting red meat, processed meats, and sweetened beverages. 2, 4

Cardiovascular Risk Reduction

Prescribe moderate- to high-intensity statins for all adults aged ≥50 years with CKD, regardless of GFR category. 1, 2 For adults 18-49 years, use statins if they have coronary disease, diabetes, prior stroke, or 10-year coronary event risk >10%. 2

Continue statin therapy until dialysis or transplantation. 1

Use aspirin for secondary prevention in those with established cardiovascular disease; consider for primary prevention in high-risk individuals, balanced against bleeding risk. 1

Monitoring Strategy

Reassess eGFR, serum creatinine, potassium, bicarbonate, and urine albumin-to-creatinine ratio every 3 months for patients with CKD stage 3b or higher. 4

Monitor urinary albumin and eGFR 1-4 times per year depending on CKD stage. 2

For patients with albuminuria ≥300 mg/g, target a 30% or greater reduction in urinary albumin through ACE inhibitor/ARB therapy, SGLT2 inhibitors (if diabetic), and blood pressure control. 2, 3

Medication Safety

Stop all NSAIDs immediately—they accelerate kidney decline and increase cardiovascular risk. 3, 4

Adjust doses of all renally cleared medications based on creatinine clearance. 3

Discontinue proton pump inhibitors unless absolutely necessary, and eliminate all dietary supplements and herbal remedies, as many contain nephrotoxic compounds. 4

Nephrology Referral Criteria

Refer to nephrology immediately if:

• eGFR <30 mL/min/1.73 m² (CKD stage 4 or higher) 4
• Albuminuria ≥300 mg/g 5
• Rapid GFR decline (>5 mL/min/1.73 m² per year or >25% decline in GFR category) 3

Common Pitfalls to Avoid

Do not withhold ACE inhibitors/ARBs due to fear of creatinine elevation—small increases (≤30%) are expected and acceptable. 3

Do not delay SGLT2 inhibitor initiation in diabetic patients—these provide proven kidney and cardiovascular protection independent of glucose lowering. 3, 4

Do not overlook albuminuria assessment—this is the single most important prognostic factor and treatment target. 3

Do not use combination ACE inhibitor + ARB therapy—insufficient evidence for benefit and increased harm risk. 3

Ensure adequate hydration before contrast procedures to prevent contrast-induced nephropathy. 3