Management of Chronic Kidney Disease
In patients with CKD, particularly older adults with diabetes and hypertension, initiate an ACE inhibitor or ARB as first-line therapy (titrated to maximum tolerated dose), target blood pressure ≤130/80 mm Hg (or <120 mm Hg systolic when tolerated in those with albuminuria ≥30 mg/24h), implement sodium restriction <2 g/day, and monitor GFR and albuminuria at intervals determined by CKD stage and albuminuria severity. 1, 2, 3
Blood Pressure Management Algorithm
Target Blood Pressure Based on Albuminuria Status
For patients with albuminuria <30 mg/24h: Target BP ≤140/90 mm Hg using standardized office measurement 1
For patients with albuminuria ≥30 mg/24h: Target BP ≤130/80 mm Hg, with consideration of <120 mm Hg systolic when tolerated based on the most recent KDIGO 2021 guidelines 1, 3
In elderly patients with CKD: The 2021 KDIGO guidelines support targeting systolic BP 120-129 mm Hg when tolerated, though this requires gradual escalation with close monitoring for orthostatic hypotension, electrolyte disorders, and acute kidney function deterioration 1, 3
Critical Monitoring for Blood Pressure Treatment
Check for postural dizziness and orthostatic hypotension regularly when treating with BP-lowering drugs 1
Use standardized office BP measurement or out-of-office BP monitoring to avoid overtreatment from white coat hypertension 2, 3
In elderly patients, tailor BP regimens by carefully considering age, comorbidities, and other therapies with gradual escalation 1
Pharmacologic Management
Renin-Angiotensin-Aldosterone System (RAAS) Inhibition
For albuminuria 30-300 mg/24h (moderately increased): Use an ACE inhibitor or ARB in diabetic adults with CKD 1
For albuminuria >300 mg/24h (severely increased): Strongly recommend an ACE inhibitor or ARB in both diabetic and non-diabetic adults with CKD (Level 1B recommendation) 1
Titrate to maximum approved dose: The proven benefits in clinical trials were achieved using maximal doses of RAAS inhibitors 3
Monitor serum creatinine and potassium: Check within 2-4 weeks after initiating or adjusting RAAS inhibitor therapy 2, 3
Accept modest creatinine increases: Continue ACE inhibitor/ARB therapy unless serum creatinine increases by more than 30% within 4 weeks, as increases up to 30% are expected and acceptable 2
Critical Contraindications and Warnings
Never combine ACE inhibitor + ARB: Dual RAAS blockade increases risk of hyperkalemia, hypotension, and acute kidney injury without additional benefit, as demonstrated in the VA NEPHRON-D trial 1, 2, 4, 5
Do not combine with direct renin inhibitors: Avoid aliskiren with ACE inhibitors or ARBs in patients with diabetes or renal impairment (GFR <60 mL/min) 4, 5
Manage hyperkalemia without stopping RAAS inhibitors when possible: Use potassium-wasting diuretics or potassium binders to allow continuation of critical renal and cardiovascular protective therapy 2, 3
Lifestyle Modifications
Dietary Interventions
Sodium restriction: Limit dietary sodium to <2 g/day (<90 mmol/day) to enhance blood pressure control and slow CKD progression 1, 2, 3
Physical Activity and Smoking Cessation
Regular exercise: Encourage 30 minutes of moderate-intensity physical activity 5 times per week, or cumulative duration of at least 150 minutes per week 1, 2, 3
Smoking cessation: Mandatory recommendation for all patients with CKD who smoke 1
Glycemic Control in Diabetic Patients
Target hemoglobin A1c level of approximately 7% to reduce proteinuria and slow CKD progression 1
Monitor for hypoglycemia when combining RAAS inhibitors with antidiabetic medications, as ACE inhibitors and ARBs may cause increased blood-glucose-lowering effect 5
Monitoring Strategy
Frequency of GFR and Albuminuria Assessment
Annual monitoring: For patients at standard risk of progression 1
More frequent monitoring: For individuals at higher risk of progression or where measurement will impact therapeutic decisions 1
Define progression: Based on decline in GFR category accompanied by ≥25% drop in eGFR from baseline, or sustained decline in eGFR of ≥5 mL/min/1.73 m²/year 1
Laboratory Monitoring After Medication Changes
Check serum creatinine, potassium, and bicarbonate 2-4 weeks after any medication changes, particularly when initiating or adjusting RAAS inhibitors 2, 3
Small fluctuations in GFR are common and not necessarily indicative of progression 1
Risk Factor Identification and Management
Factors Associated with CKD Progression
Identify and address the following risk factors: cause of CKD, level of GFR, level of albuminuria, age, sex, race/ethnicity, elevated blood pressure, hyperglycemia, dyslipidemia, smoking, obesity, history of cardiovascular disease, and ongoing exposure to nephrotoxic agents 1
Nephrotoxin Avoidance
NSAIDs: In elderly, volume-depleted, or renally compromised patients, coadministration of NSAIDs with ACE inhibitors or ARBs may result in deterioration of renal function including possible acute renal failure 4, 5
Monitor renal function periodically in patients receiving RAAS inhibitors and NSAID therapy 4, 5
Acute Kidney Injury Risk
All people with CKD are considered to be at increased risk of AKI (Level 1A recommendation) 1
CKD remains an independent risk factor for AKI even after adjustment for comorbid conditions 1
Mounting evidence suggests that AKI is a risk factor for both incident CKD and progression of CKD 1
Cardiovascular Disease Management
The level of care for ischemic heart disease offered to people with CKD should not be prejudiced by their CKD (Level 1A recommendation) 1
Persons with CKD are more likely to have a cardiovascular event than to progress to end-stage renal disease 1
CKD patients have worse prognosis with higher mortality rates after acute myocardial infarction and higher risk for recurrent myocardial infarction, heart failure, and sudden cardiac death 1
Common Pitfalls to Avoid
Do not use routine office BP measurements alone when targeting intensive BP lowering to <120 mm Hg—this can lead to overtreatment and adverse events; use standardized measurement techniques 3
Do not discontinue RAAS inhibitors prematurely for modest creatinine increases (<30% rise within 4 weeks) or manageable hyperkalemia—these medications provide critical renal and cardiovascular protection 2, 3
Do not delay treatment in elderly patients due to age alone—the benefits of BP control and RAAS inhibition extend to older adults when treatment is carefully titrated 1, 3
Do not overlook postural hypotension in elderly patients on multiple BP medications—regularly assess for orthostatic symptoms and blood pressure changes 1