What are the guidelines for Chronic Kidney Disease (CKD) management?

From the Guidelines

Chronic Kidney Disease (CKD) management should prioritize early detection, slowing progression, and managing complications, with a focus on blood pressure control, diabetes management, and lifestyle modifications, as recommended by the KDIGO 2020 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease 1.

Key Recommendations

• Regular monitoring of kidney function through estimated glomerular filtration rate (eGFR) and urine albumin-to-creatinine ratio (UACR) is essential.
• Blood pressure control is critical, with a target of <130/80 mmHg for most CKD patients, using ACE inhibitors (like lisinopril 10-40 mg daily) or ARBs (such as losartan 50-100 mg daily) as first-line agents, especially in those with albuminuria, as suggested by the KDIGO guideline 1 and supported by previous studies 1.
• For diabetes management in CKD, SGLT2 inhibitors (empagliflozin 10-25 mg daily or dapagliflozin 10 mg daily) are recommended as they provide both cardiovascular and kidney protection, as stated in the KDIGO 2020 guideline 1.
• Dietary modifications include sodium restriction (<2g/day), moderate protein intake (0.8g/kg/day for non-dialysis patients), and potassium restriction in advanced CKD, as recommended by the American Heart Association 1 and supported by the KDIGO guideline 1.
• Metabolic acidosis should be corrected with oral sodium bicarbonate (500-1000 mg three times daily) to maintain serum bicarbonate >22 mEq/L.
• Anemia management includes iron supplementation and erythropoiesis-stimulating agents when hemoglobin falls below 10 g/dL.
• Mineral bone disorder requires monitoring calcium, phosphorus, and PTH levels, with phosphate binders and vitamin D analogs as needed.

Implementation

• Regular nephrology referral is recommended for eGFR <30 mL/min/1.73m², rapid decline in kidney function, persistent albuminuria, resistant hypertension, or electrolyte abnormalities, as suggested by the KDOQI US commentary on the 2012 KDIGO clinical practice guideline for the evaluation and management of CKD 1.
• The KDIGO 2020 guideline provides evidence-based recommendations for the management of CKD, and its implementation should be tailored to individual patient needs, taking into account the severity of albuminuria, comorbidities, and other factors, as stated in the guideline 1.

From the Research

CKD Guidelines

• The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommend blood pressure (BP) control of <140/90 mmHg in patients without albuminuria and <130/80 mmHg in patients with albuminuria to prevent CKD progression 2.
• Lifestyle modifications such as walking, weight loss, low-protein diet (LPD), adherence to the alternate Mediterranean (aMed) diet, and Alternative Healthy Eating Index (AHEI)-2010 can slow the progression of CKD 2.
• Smoking and binge alcohol drinking increase the risk of CKD progression 2.
• Medical therapies aim to target epigenetic alterations, fibrosis, and inflammation, with approved treatments including RAAS blockade, sodium-glucose cotransporter-2 (SGLT2) inhibitors, pentoxifylline, and finerenone 2.

Lifestyle Modifications

• Current CKD management guidelines recommend that patients adhere to a healthy diet, perform ≥150 minutes per week of physical activity, manage their body weight, abstain from tobacco use, and limit alcohol 3.
• Lifestyle behaviour change interventions for CKD patients frequently use education, goal setting, feedback, monitoring, and social support 4.
• The most promising interventions include education and use a variety of intervention functions (persuasion, modelling, and incentivisation) 4.

Medical Therapies

• Angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB) are two classes of antihypertensive drugs that act on the renin-angiotensin-aldosterone system, with beneficial effects on kidney outcomes and survival in people with CKD 5.
• However, the effectiveness of ACEi and ARB in the subgroup of people with early CKD (stage 1 to 3) is less certain, with low or very low certainty evidence 5.
• Dietary interventions may increase health-related quality of life, eGFR, and serum albumin, and lower blood pressure and serum cholesterol levels, but have uncertain effects on mortality, cardiovascular events, and ESKD among people with CKD 6.