What is the critical management approach for an adult patient with a history of Chronic Kidney Disease (CKD), possibly with diabetes, hypertension, or cardiovascular disease, presenting with impaired renal function?

Critical Management of CKD

For adults with CKD presenting with impaired renal function, immediately initiate SGLT-2 inhibitors (if eGFR ≥20 mL/min/1.73 m²), target systolic blood pressure <120 mmHg when tolerated, and prescribe ACE inhibitors or ARBs for patients with albuminuria ≥300 mg/24 hours, while avoiding NSAIDs entirely. 1

Immediate Risk Stratification

Classify CKD severity using the three-dimensional KDIGO system incorporating cause, GFR category, and albuminuria level to guide treatment intensity 1:

• Very high risk: eGFR <30 mL/min/1.73 m² with any albuminuria, OR eGFR 30-59 with albuminuria >30 mg/mmol, requiring aggressive intervention 1
• High risk: eGFR 30-44 with albuminuria <3 mg/mmol, OR eGFR 45-59 with albuminuria 3-30 mg/mmol 1
• Moderate risk: eGFR ≥60 with albuminuria 3-30 mg/mmol, OR eGFR 45-59 with albuminuria <3 mg/mmol 1

Core Pharmacologic Interventions

SGLT-2 Inhibitors (First-Line for Most Patients)

Initiate SGLT-2 inhibitors in all adults with CKD regardless of diabetes status, provided eGFR ≥20 mL/min/1.73 m² 1. These agents reduce cardiovascular mortality, kidney failure progression, and hospitalization 1, 2. Continue therapy even if eGFR drops below 20 mL/min/1.73 m² until dialysis initiation 1.

Blood Pressure Management

Target systolic BP <120 mmHg using standardized office measurement when tolerated 1. This represents updated 2024 guidance that is more aggressive than prior recommendations 1.

• For patients with albuminuria <30 mg/24 hours: Maintain BP ≤140/90 mmHg 1
• For patients with albuminuria ≥30 mg/24 hours: Target BP ≤130/80 mmHg 1
• Exception: Use less intensive targets in patients with frailty, high fall risk, limited life expectancy, or symptomatic orthostatic hypotension 1

RAAS Inhibition for Proteinuria

Prescribe ACE inhibitors or ARBs for all patients with albuminuria >300 mg/24 hours (both diabetic and non-diabetic) 1. These medications slow CKD progression by reducing proteinuria through RAAS interruption 1. Do not combine ACE inhibitors with ARBs, as evidence does not support dual therapy 1.

Cardiovascular Risk Reduction

Initiate statin therapy immediately in all CKD patients for cardiovascular protection, as CVD is the leading cause of death in this population 3, 4, 5. Use rosuvastatin 5-10 mg daily in CKD stage 3B 3.

Critical Medications to Avoid

Never prescribe NSAIDs in CKD patients regardless of symptom severity or CKD stage 6, 3, 5. NSAIDs cause acute kidney injury, accelerate CKD progression, worsen heart failure, and increase hyperkalemia risk 6, 3. For pain management, consider alternatives such as low-dose colchicine or short-course glucocorticoids 3.

Lifestyle and Dietary Modifications

Implement the following evidence-based interventions 1:

• Sodium restriction: <2 g sodium per day (<90 mmol/day or <5 g sodium chloride/day) 1
• Protein intake: Maintain 0.8 g/kg/day in CKD G3-G5; avoid high protein intake >1.3 g/kg/day 1
• Physical activity: 150 minutes of moderate-intensity exercise weekly 1
• Smoking cessation: Essential for slowing progression 1
• Weight management: Target BMI 20-25 kg/m² 1
• Glycemic control: HbA1c target of 7% in diabetic patients 1

Monitoring and Complication Management

Monitoring Frequency Based on Risk

Adjust monitoring intensity according to GFR and albuminuria categories 1:

• Very high risk (eGFR <30 or severe albuminuria): Monitor 4 times per year 1
• High risk: Monitor 3 times per year 1
• Moderate risk: Monitor 2 times per year 1
• Low risk: Monitor annually 1

Specific Complications to Monitor

Screen for and manage the following CKD complications 5:

• Hyperkalemia: Monitor potassium within 2-4 weeks after adjusting RAAS inhibitors or diuretics 7
• Metabolic acidosis: Assess serum bicarbonate regularly 5
• Anemia: Consider intravenous iron for iron deficiency to improve functional status and quality of life 6; initiate erythropoietin-stimulating agents when hemoglobin <10 g/dL in dialysis patients 8
• Mineral bone disease: Monitor calcium, phosphorus, PTH, and vitamin D 5

Acute Kidney Injury Prevention

Recognize that all CKD patients are at increased risk for AKI 1. Avoid nephrotoxic exposures including NSAIDs, aminoglycosides, and contrast agents 1, 3. When contrast is necessary, use iso-osmolar agents and minimize volume 6.

Nephrology Referral Criteria

Refer promptly to nephrology when 5:

• eGFR <30 mL/min/1.73 m² 5
• Albuminuria ≥300 mg per 24 hours 5
• Rapid eGFR decline (>5 mL/min/1.73 m² per year or >25% decline confirmed by repeat testing) 1
• Refractory hypertension despite multiple agents 1
• Unexplained hematuria or suspected glomerulonephritis 1

Common Pitfalls to Avoid

Do not discontinue RAAS inhibitors for modest creatinine increases (<30% rise), as these medications provide long-term kidney and cardiovascular protection 7. Only discontinue for symptomatic hypotension, uncontrolled hyperkalemia, or creatinine rise >30% 7.

Do not assume linear CKD progression—fluctuations in kidney function are common and do not necessarily indicate true progression 1. Define progression as both a change in GFR category AND ≥25% decline in eGFR to avoid misinterpretation of minor variations 1.

Do not overlook cardiovascular disease management, as CKD patients are more likely to die from cardiovascular events than progress to kidney failure 1, 4. Aggressive cardiovascular risk reduction is paramount 4, 5.

Do not initiate uric acid-lowering therapy for asymptomatic hyperuricemia, as it does not delay CKD progression 7. Reserve treatment for symptomatic gout only 7.