What are the treatment guidelines for an adult patient with Chronic Kidney Disease (CKD), potentially with a history of conditions like diabetes or hypertension?

Chronic Kidney Disease Treatment Guidelines

Adults with CKD should be treated with a systolic blood pressure target of <120 mm Hg when tolerated using standardized office measurement, combined with renin-angiotensin system inhibitors (ACEi or ARB) for those with albuminuria, SGLT2 inhibitors for cardiovascular and kidney protection, lifestyle modifications including sodium restriction to <2 g/day, and statin therapy for cardiovascular risk reduction. 1

Blood Pressure Management

Target Blood Pressure

• Target systolic BP <120 mm Hg in adults with CKD when tolerated, using standardized office BP measurement 1
• For patients with albuminuria <30 mg/24h: maintain BP ≤140/90 mm Hg 1
• For patients with albuminuria ≥30 mg/24h: maintain BP ≤130/80 mm Hg 1
• Less intensive BP targets should be considered in patients with frailty, high fall risk, limited life expectancy, or symptomatic postural hypotension 1

Blood Pressure Monitoring Approach

• Use standardized office BP measurement as the primary method 1
• Check BP within 2-4 weeks after initiating or increasing RASi dose, depending on current GFR and potassium levels 1
• For children with CKD: monitor with ambulatory BP monitoring (ABPM) annually and standardized office BP every 3-6 months 1

Pharmacologic Therapy

Renin-Angiotensin System Inhibitors (First-Line for Albuminuria)

• ACEi or ARB are strongly recommended for patients with severely increased albuminuria (≥300 mg/24h) regardless of diabetes status 1
• ACEi or ARB are recommended for diabetic patients with moderately-to-severely increased albuminuria (≥30 mg/24h) 1
• For non-diabetic patients with moderately increased albuminuria (30-300 mg/24h): consider ACEi or ARB 1
• Use the highest approved tolerated dose to achieve proven benefits from clinical trials 1
• Never combine ACEi with ARB - evidence shows harm with combination therapy 2

Managing RASi Side Effects

• Monitor serum creatinine, potassium, and BP within 2-4 weeks of initiation or dose increase 1
• Continue RASi therapy even if serum creatinine rises, unless the increase is excessive 1
• Hyperkalemia can often be managed with potassium-lowering measures rather than stopping RASi 1

SGLT2 Inhibitors (Foundational Therapy)

• SGLT2 inhibitors are now recommended as foundational therapy alongside RASi for CKD patients with and without type 2 diabetes 2, 3
• These agents prevent CKD progression, reduce fatal and non-fatal kidney and cardiovascular events, reduce heart failure hospitalization, and decrease all-cause mortality 3
• Consider adding SGLT2 inhibitor for patients with diabetes or high cardiovascular risk 2

Cardiovascular Risk Reduction

• Initiate statin therapy for all adults ≥50 years with eGFR <60 mL/min/1.73 m² 2
• Consider statin/ezetimibe combination therapy 2
• For diabetic CKD with albuminuria: consider finerenone (a non-steroidal mineralocorticoid receptor antagonist) 2

Lifestyle Modifications

Dietary Sodium Restriction

• Limit sodium intake to <2 g/day (equivalent to <5 g sodium chloride/day) 1
• More intensive target of <1500 mg/day may be considered for optimal BP control 2
• Exception: do not restrict sodium in patients with sodium-wasting nephropathy 1

Protein Intake

• Maintain protein intake of 0.8 g/kg body weight/day for adults with CKD G3-G5 1
• Avoid high protein intake (>1.3 g/kg/day) in adults with CKD at risk of progression 1
• For metabolically stable patients at risk of kidney failure who are willing and able: consider very low-protein diet (0.3-0.4 g/kg/day) supplemented with essential amino acids or ketoacid analogs under close supervision 1
• Do not restrict protein in children with CKD due to growth impairment risk - target upper end of normal range 1
• In older adults with frailty or sarcopenia: consider higher protein and calorie targets 1

Physical Activity and Weight Management

• Encourage ≥150 minutes per week of aerobic exercise 2, 4
• Walking and weight loss slow CKD progression 5
• Achieve and maintain healthy body mass index of 20-25 kg/m² 1

Other Lifestyle Interventions

• Smoking cessation is essential - smoking increases CKD progression risk 1, 5
• Limit alcohol consumption - avoid binge drinking which increases CKD progression 5
• Consider plant-based Mediterranean-style diet for cardiovascular and kidney benefits 6, 5
• Limit intake of meats, high-fructose corn syrup, and alcohol which may contribute to inflammation 6

Diabetes Management (for Diabetic CKD)

Glycemic Control

• Target HbA1c ~7.0% to prevent microvascular complications 2
• Do not target HbA1c <7.0% if patient is at risk of hypoglycemia 2
• Good diabetes control is linked to reduction of proteinuria and slowed CKD progression 1

Metabolic Acidosis Management

• For patients with serum bicarbonate <22 mmol/L: provide oral bicarbonate supplementation to maintain bicarbonate within normal range, unless contraindicated 1

Monitoring and Follow-up

Frequency of Monitoring

• For CKD G3b (eGFR 30-44): monitor serum creatinine, eGFR, electrolytes, and urine albumin-to-creatinine ratio 3 times per year 2
• After RASi initiation or dose adjustment: check BP, creatinine, and potassium within 2-4 weeks 1

Defining CKD Progression

• CKD progression is defined as both a change in GFR category AND ≥25% decline in eGFR sustained over time 1, 2
• This prevents misinterpretation of small GFR changes (e.g., 61 to 59 mL/min/1.73 m²) as progression 1

Nephrology Referral

• Refer to nephrologist for patients with advanced CKD or complications 7

Acute Kidney Injury Prevention

• All people with CKD should be considered at increased risk of AKI 1
• CKD is an independent risk factor for AKI, and AKI increases risk of CKD progression 1

Contrast Media Precautions

For patients with eGFR <60 mL/min/1.73 m² undergoing procedures with iodinated contrast:

• Avoid high-osmolar agents 1
• Use lowest possible contrast dose 1
• Withdraw potentially nephrotoxic agents before and after procedure 1
• Provide adequate hydration with saline before, during, and after procedure 1
• Measure GFR 48-96 hours after procedure 1
• Avoid gadolinium-containing contrast in patients with eGFR <15 mL/min/1.73 m² unless no alternative exists 1

Critical Medication Considerations

NSAIDs

• Never prescribe NSAIDs in CKD stage 3B or higher - they significantly increase risk of acute kidney injury and CKD progression 6
• For inflammatory conditions: use low-dose colchicine or short-course glucocorticoids instead 6

Pain Management Alternatives

• Low-dose colchicine is preferred for inflammatory conditions given CKD 6
• Short-course, low-dose oral glucocorticoids for acute symptom control 6
• Physical therapy with supervised active exercise interventions 6

Cardiovascular Disease Management

• CKD patients should receive the same level of care for ischemic heart disease as those without CKD 1
• Persons with CKD are more likely to have cardiovascular events than to progress to end-stage renal disease 1
• CKD patients have worse prognosis after acute myocardial infarction and higher risk of recurrent events 1

Common Pitfalls to Avoid

• Do not combine ACEi with ARB - this causes harm 2
• Do not discontinue RASi for mild creatinine elevations or manageable hyperkalemia 1
• Do not use NSAIDs even for short-term use in CKD stage 3B or higher 6
• Do not restrict protein in children with CKD or in malnourished adults 1
• Do not overlook statin therapy - cardiovascular disease is the leading cause of mortality in CKD 6
• Do not ignore SGLT2 inhibitor therapy - uptake has been slow despite strong evidence 3