Treatment Plan for Chronic Kidney Disease
Core Pharmacologic Strategy
All CKD patients should receive SGLT2 inhibitors as foundational therapy, combined with maximum-dose RAS inhibition (ACE inhibitor or ARB) when albuminuria or hypertension is present, plus statin-based lipid therapy for cardiovascular protection. 1
First-Line Medications
SGLT2 inhibitors: Initiate in most CKD patients and continue until dialysis or transplant—this represents the most significant advancement in CKD management with robust evidence for delaying progression and reducing cardiovascular complications 1
RAS inhibition (ACE inhibitor or ARB): Prescribe at maximum tolerated dose when albuminuria is present; first-line when hypertension exists; titrate to highest approved dose that is tolerated to maximize kidney protection 1, 2
Statin therapy: Mandatory for all adults ≥50 years with eGFR <60 mL/min/1.73 m² (CKD G3a-G5); use statin or statin/ezetimibe combination to maximize absolute LDL cholesterol reduction 2, 1
Additional Pharmacologic Considerations for Type 2 Diabetes
GLP-1 receptor agonists: Add when glycemic targets not achieved despite metformin and SGLT2 inhibitor, prioritizing agents with documented cardiovascular benefits 2
Nonsteroidal MRA (finerenone): May be added to RAS inhibitor and SGLT2 inhibitor in T2D patients with CKD; select patients with consistently normal serum potassium (≤4.8 mmol/L) and monitor potassium regularly 2
Blood Pressure Management
Target systolic blood pressure <120 mmHg for most CKD patients—a more aggressive target than previous guidelines, supported by cardiovascular outcome data. 1
For patients without albuminuria: Target BP <140/90 mmHg 1
For patients with albuminuria ≥30 mg/24h: Target BP <130/80 mmHg 1
When albuminuria is present, ACE inhibitor or ARB must be first-line antihypertensive therapy 1
Often require all three classes (RAS inhibitor, dihydropyridine calcium channel blocker, and diuretic) to attain BP targets 2
Cardiovascular Risk Reduction
Lipid Management by Age and GFR
Adults ≥50 years with eGFR <60 mL/min/1.73 m²: Statin or statin/ezetimibe combination (strong recommendation) 2
Adults ≥50 years with eGFR ≥60 mL/min/1.73 m²: Statin therapy 2
Adults 18-49 years: Statin therapy if any of the following: known coronary disease, diabetes mellitus, prior ischemic stroke, or 10-year cardiovascular risk >10% 2
PCSK9 inhibitors: Consider in CKD patients who have an indication for their use 2
Antiplatelet Therapy
Low-dose aspirin: Recommended for secondary prevention in CKD patients with established ischemic cardiovascular disease 2, 1
Consider P2Y12 inhibitors when aspirin intolerance exists 2
Lifestyle Modifications
Physical Activity
Moderate-intensity physical activity for at least 150 minutes per week, adjusted to cardiovascular and physical tolerance 2, 1
For patients at higher risk of falls, provide specific advice on intensity (low, moderate, or vigorous) and type of exercises (aerobic vs. resistance) 2
Encourage weight loss for patients with obesity and CKD 2
Dietary Management
Adopt healthy, diverse diets with higher consumption of plant-based foods compared to animal-based foods and lower consumption of ultra-processed foods 2, 1
Consider plant-based "Mediterranean-style" diet in addition to lipid-modifying therapy to reduce cardiovascular risk 2
Maintain protein intake at 0.8 g/kg body weight/day in adults with CKD G3-G5 2, 1
Avoid high protein intake (>1.3 g/kg body weight/day) in adults with CKD at risk of progression 2, 1
Use renal dietitians to educate about dietary adaptations regarding sodium, phosphorus, potassium, and protein intake 2
Management of CKD Complications
Hyperkalemia Management
Be aware of variability in potassium measurements and factors influencing measurement including diurnal/seasonal variation 2
Implement individualized approach including dietary and pharmacologic interventions for CKD G3-G5 patients with emergent hyperkalemia 2
Limit intake of foods rich in bioavailable potassium (e.g., processed foods) for CKD G3-G5 patients with history of hyperkalemia 2
Metabolic Acidosis
Consider pharmacological treatment with or without dietary intervention to prevent development of acidosis (e.g., serum bicarbonate <18 mmol/L in adults) 2
Monitor treatment to ensure bicarbonate does not exceed upper limit of normal and does not adversely affect BP control, serum potassium, or fluid status 2
Hyperuricemia and Gout
Offer uric acid-lowering intervention for symptomatic hyperuricemia (gout) 2
Prescribe xanthine oxidase inhibitors in preference to uricosuric agents 2
For acute gout treatment, use low-dose colchicine or intra-articular/oral glucocorticoids—NSAIDs are preferable to avoid due to nephrotoxicity risk 2, 1
Do NOT use agents to lower serum uric acid in asymptomatic hyperuricemia to delay CKD progression 2
Monitoring and Risk Assessment
Use validated risk prediction tools, including the Kidney Failure Risk Equation, to identify patients at high risk of progressive kidney disease 1, 3
Test people at risk for CKD using both urine albumin measurement and assessment of GFR 1
Estimate 10-year cardiovascular risk using a validated risk tool 2
Perform thorough medication review periodically and at transitions of care to assess adherence, continued indication, and potential drug interactions 1
Referral to Nephrology
Refer adults with CKD to specialist kidney care when they have: 1
- ACR ≥30 mg/g (3 mg/mmol) or PCR ≥200 mg/g (20 mg/mmol)
- Persistent hematuria
- Any sustained decrease in eGFR
- eGFR <30 mL/min/1.73 m² 4
- Albuminuria ≥300 mg per 24 hours 4
- Rapid decline in estimated GFR 4
Critical Pitfalls to Avoid
Never prescribe NSAIDs in CKD due to nephrotoxicity risk and potential for acute kidney injury 1
Do not discontinue RAS inhibitors due to modest increases in serum creatinine or potassium unless specific contraindications exist 1
Do not use uric acid-lowering agents for asymptomatic hyperuricemia to delay CKD progression 2, 1
Avoid high protein intake (>1.3 g/kg/day) in adults with CKD at risk of progression 2, 1
Consider GFR when dosing medications cleared by the kidneys 1