What is the recommended treatment plan for an adult patient with chronic kidney failure, a history of diabetes or hypertension, and impaired renal function?

Comprehensive Treatment Plan for Chronic Kidney Failure with Diabetes or Hypertension

Foundational Pharmacologic Strategy

Initiate an SGLT2 inhibitor immediately when eGFR ≥20 mL/min/1.73 m², regardless of diabetes status or glycemic control, as this provides kidney protection, reduces cardiovascular events, and decreases mortality. 1, 2

• Continue SGLT2 inhibitors (dapagliflozin 10 mg daily or canagliflozin 100 mg daily) until dialysis initiation or transplantation, even as eGFR declines below 20 mL/min/1.73 m². 1, 2
• Add metformin when eGFR ≥30 mL/min/1.73 m² for additional glycemic control in diabetic patients. 1
• Reduce metformin to 1000 mg daily when eGFR is 30-44 mL/min/1.73 m², and discontinue when eGFR falls below 30 mL/min/1.73 m² due to lactic acidosis risk. 1

Blood Pressure and Kidney Protection

Initiate an ACE inhibitor or ARB in all patients with diabetes, hypertension, AND albuminuria, titrating to the maximum tolerated dose. 3, 1, 2

• Target blood pressure <130/80 mmHg in patients with albuminuria; <140/90 mmHg in those without albuminuria. 4
• Monitor serum creatinine and potassium within 2-4 weeks after starting or increasing ACE inhibitor/ARB doses. 3, 1
• Continue therapy unless creatinine rises >30% within 4 weeks—this degree of increase warrants evaluation for acute kidney injury, volume depletion, or renal artery stenosis. 1
• Do not immediately discontinue ACE inhibitors/ARBs for hyperkalemia; first manage potassium through dietary modification, diuretics, sodium bicarbonate, or GI cation exchangers. 1

Cardiovascular Risk Reduction

Initiate statin therapy in all adults ≥50 years with CKD, regardless of baseline LDL cholesterol. 3

• For eGFR <60 mL/min/1.73 m² (stages G3a-G5): Use statin or statin/ezetimibe combination (Grade 1A). 3
• For eGFR ≥60 mL/min/1.73 m² (stages G1-G2): Use statin alone (Grade 1B). 3
• For adults 18-49 years with diabetes, prior MI/stroke, or 10-year cardiovascular risk >10%: Initiate statin therapy (Grade 2A). 3
• Choose high-intensity regimens (atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily) to maximize LDL reduction. 3, 5, 2

Advanced Kidney Protection for High-Risk Patients

Add a GLP-1 receptor agonist if glycemic targets are not met with metformin and SGLT2 inhibitors, or if these agents cannot be used. 3, 1

• Consider adding finerenone (nonsteroidal MRA) for patients with type 2 diabetes who have persistent albuminuria ≥30 mg/g despite first-line therapy and normal potassium levels. 3, 1, 2

Glycemic Monitoring and Targets

Target HbA1c between 7.0-8.0% in CKD patients with multiple comorbidities and high hypoglycemia risk. 5

• Check HbA1c every 3 months when therapy changes or targets are not met, and at least twice yearly in stable patients. 1, 5
• Reduce insulin or sulfonylurea doses by 10-20% when initiating SGLT2 inhibitors to prevent hypoglycemia. 5

Antiplatelet Therapy

Prescribe low-dose aspirin (81 mg daily) for secondary prevention in patients with established ischemic cardiovascular disease. 3, 2

• Consider P2Y12 inhibitors (e.g., clopidogrel) when aspirin is not tolerated. 3

Lifestyle Modifications

Restrict dietary protein to 0.8 g/kg/day for patients with CKD not on dialysis. 1, 2

• Limit sodium intake to <2 g/day (<5 g sodium chloride/day). 1, 2
• Advise moderate-intensity physical activity for at least 150 minutes per week, or to a level compatible with cardiovascular tolerance. 1, 5, 2
• Strongly recommend tobacco cessation for all patients who use tobacco products. 1
• Consider a plant-based Mediterranean-style diet in addition to pharmacologic therapy. 3
• Limit intake of foods rich in bioavailable potassium (especially processed foods) for patients with history of hyperkalemia. 3

Anemia Management

Monitor hemoglobin regularly and treat anemia with iron supplementation before or with erythropoiesis-stimulating agents (ESAs). 2

• For adult CKD patients on dialysis: Initiate ESA when hemoglobin <10 g/dL; reduce or interrupt if hemoglobin approaches or exceeds 11 g/dL. 6
• For adult CKD patients not on dialysis: Consider ESA only when hemoglobin <10 g/dL and risk of transfusion is high; reduce or interrupt if hemoglobin exceeds 10 g/dL. 6
• Starting dose: 50-100 Units/kg three times weekly intravenously or subcutaneously. 6
• Monitor hemoglobin weekly until stable, then at least monthly. 6

Monitoring Schedule

Reassess every 3-6 months with eGFR, serum creatinine, electrolytes, urine albumin-to-creatinine ratio, hemoglobin, blood pressure, and lipid panel. 2

Nephrology Referral Criteria

Refer immediately to nephrology when eGFR <30 mL/min/1.73 m², with persistent electrolyte abnormalities, or uncontrolled hypertension despite multiple agents. 2

Critical Medications to AVOID

Avoid NSAIDs, metformin when eGFR <30 mL/min/1.73 m², and sulfonylureas due to increased risks of acute kidney injury, lactic acidosis, and hypoglycemia. 2

• NSAIDs are particularly dangerous for acute gout treatment in CKD; use low-dose colchicine or intra-articular/oral glucocorticoids instead. 3

Common Pitfalls to Avoid

• Do not target hemoglobin >11 g/dL with ESAs, as this increases mortality and cardiovascular events. 6
• Do not discontinue SGLT2 inhibitors prematurely due to modest eGFR declines; kidney and cardiovascular benefits persist at lower eGFR levels. 1
• Do not withhold ACE inhibitors/ARBs for mild hyperkalemia or creatinine increases <30%; attempt medical management first. 1
• Educate patients on euglycemic ketoacidosis risk with SGLT2 inhibitors, especially during acute illness. 5