What are the treatment guidelines for a patient with Chronic Kidney Disease (CKD), particularly those with underlying conditions such as diabetes or hypertension?

CKD Treatment Guidelines

All patients with CKD should receive SGLT2 inhibitors (when eGFR ≥20 mL/min/1.73 m²) and ACE inhibitors or ARBs (when albuminuria ≥30 mg/g is present), combined with statins, blood pressure control to <130/80 mmHg, and lifestyle modifications including sodium restriction to <2 g/day. 1, 2, 3

Initial Assessment and Risk Stratification

• Measure both eGFR and urine albumin-to-creatinine ratio (ACR) at baseline to stage CKD and determine prognosis 1, 4
• Check serum creatinine, complete metabolic panel, CBC, lipid panel, and urinalysis 4
• For diabetic patients, obtain HbA1c 3
• Monitor eGFR and albuminuria at least annually, more frequently (every 1-6 months) for patients at higher risk of progression or with eGFR <60 mL/min/1.73 m² 1, 4
• Assess for cardiovascular disease, diabetes duration, hypertension, nephrotoxin exposure, and family history 4

Blood Pressure Management

Target Blood Pressure

• Target <130/80 mmHg for all CKD patients to reduce cardiovascular mortality and slow progression 1, 2, 3
• For patients without albuminuria (<30 mg/g), target <140/90 mmHg 1, 4
• For patients with albuminuria ≥30 mg/g, target <130/80 mmHg 1, 2
• Consider even lower targets for patients with severely elevated albuminuria (≥300 mg/g) 3

First-Line Antihypertensive Therapy

• Start ACE inhibitor or ARB immediately for all patients with albuminuria ≥30 mg/g, regardless of blood pressure 1, 2, 4
• Titrate to the highest approved tolerated dose 2, 4
• For albuminuria ≥300 mg/g, ACE inhibitor or ARB use is a Grade 1B recommendation 1, 4
• Monitor serum creatinine and potassium within 2-4 weeks after starting or increasing dose 3, 4
• Continue therapy unless creatinine rises >30% within 4 weeks 4

Additional Antihypertensive Agents

• Add long-acting dihydropyridine calcium channel blocker as second agent if BP remains uncontrolled 4
• Use thiazide-like diuretics (when eGFR ≥30 mL/min/1.73 m²) or loop diuretics (when eGFR <30 mL/min/1.73 m²) as needed 2
• Never combine ACE inhibitors with ARBs - this increases adverse events (hyperkalemia, AKI) without additional benefit 1, 3

Diabetes Management in CKD

SGLT2 Inhibitors (First-Line for Type 2 Diabetes)

• Initiate SGLT2 inhibitor immediately when eGFR ≥20 mL/min/1.73 m² for all patients with type 2 diabetes and CKD, regardless of glycemic control 1, 2, 3, 4
• This provides kidney protection, cardiovascular benefits, and reduces heart failure hospitalizations independent of glucose-lowering effects 1, 3
• Continue SGLT2 inhibitors even as eGFR declines until dialysis or transplantation is initiated 1, 4
• Renal and cardiovascular benefits persist down to eGFR 30 mL/min/1.73 m² 1
• Canagliflozin reduced ESRD risk by 32% in patients with advanced CKD (mean eGFR 56 mL/min/1.73 m²) 1

Metformin

• Add metformin when eGFR ≥30 mL/min/1.73 m² for additional glycemic control 1, 4
• Reduce dose to 1000 mg daily when eGFR 30-44 mL/min/1.73 m² 4
• Discontinue when eGFR <30 mL/min/1.73 m² due to lactic acidosis risk 4

GLP-1 Receptor Agonists

• Add GLP-1 RA if SGLT2 inhibitors and metformin are insufficient to meet glycemic targets or if unable to use SGLT2i or metformin 1, 2, 4
• Liraglutide reduced risk of new or worsening nephropathy by 22% 1
• Semaglutide reduced risk by 36% 1

Glycemic Targets

• Target HbA1c between 6.5-8.0%, individualized based on hypoglycemia risk, life expectancy, comorbidities, and patient preferences 3, 4
• Intensive glucose control (HbA1c ~7%) delays onset and progression of albuminuria 3
• Check HbA1c every 3 months when adjusting therapy, at least twice yearly when stable 3, 4

Advanced Therapy for Persistent Albuminuria

• Consider nonsteroidal mineralocorticoid receptor antagonist (finerenone) for patients with type 2 diabetes and persistent albuminuria ≥30 mg/g despite first-line therapy and normal potassium 1, 4
• This is for patients with high residual risk of kidney disease progression and cardiovascular events 1
• Steroidal MRAs (spironolactone, eplerenone) can be used for resistant hypertension but require close monitoring for hyperkalemia 1

Cardiovascular Risk Reduction

Statin Therapy

• Initiate statin therapy for all CKD patients with diabetes, regardless of baseline lipid levels 1, 2, 3, 4
• Target LDL-C <100 mg/dL (consider <70 mg/dL for very high risk) 4
• Do not initiate statins in type 2 diabetics on maintenance hemodialysis without specific cardiovascular indication 1

Antiplatelet Therapy

• Use aspirin lifelong for secondary prevention in those with established cardiovascular disease 1
• Consider for primary prevention in patients with high risk of atherosclerotic cardiovascular disease 1

Lifestyle Modifications

Dietary Interventions

• Restrict sodium intake to <2 g/day (<5 g salt/day) to enhance effectiveness of RAS blockade 1, 2, 3, 4
• Limit protein intake to 0.8 g/kg/day for patients with eGFR <60 mL/min/1.73 m² not on dialysis 2, 3, 4
• Avoid high protein intake >1.3 g/kg/day 2
• Implement dietary phosphate restrictions when eGFR <60 mL/min/1.73 m² 5

Other Lifestyle Measures

• Smoking cessation is mandatory - tobacco accelerates CKD progression 2, 4
• Recommend moderate-intensity physical activity for ≥150 minutes weekly, compatible with cardiovascular tolerance 3, 4
• Encourage weight management 1

Monitoring for CKD Complications

• Begin monitoring for anemia, bone disease, metabolic acidosis, and hyperkalemia when eGFR <60 mL/min/1.73 m² (Stage 3) 4
• Monitor serum creatinine, eGFR, and urine ACR at least annually for moderate-to-severe CKD 4
• For eGFR <60 mL/min/1.73 m² or GFR decline ≥4 mL/min/1.73 m²/year, monitor every 1-6 months 4
• Assess hyperkalemia, particularly in patients on ACE inhibitors/ARBs - attempt dietary modification, diuretics, sodium bicarbonate, or GI cation exchangers before discontinuing RAAS blockade 4
• Evaluate anemia, secondary hyperparathyroidism, metabolic bone disease, and electrolyte disturbances as eGFR declines 4

Nephrology Referral

• Refer to nephrologist when eGFR <30 mL/min/1.73 m² (Stage 4), or earlier if uncertainty about etiology, difficult management issues, or rapid progression 1, 4
• Specific indications include: eGFR <30 mL/min/1.73 m², albuminuria ≥300 mg/g despite treatment, rapidly declining kidney function, resistant hypertension, or electrolyte disturbances 4
• Early referral (Stage 4) reduces cost, improves quality of care, and delays dialysis 4
• Preparation for kidney replacement therapy should begin during Stage 4, well before uremic symptoms develop 4

Common Pitfalls to Avoid

• Never combine ACE inhibitors with ARBs - increases harm without benefit 1, 3
• Do not overlook cardiovascular disease management - cardiovascular events are more likely than progression to ESRD 3
• Do not delay SGLT2 inhibitor initiation waiting for poor glycemic control - benefits are independent of glucose lowering 1, 3
• Avoid nephrotoxins and monitor during volume depletion - all CKD patients are at increased risk for acute kidney injury 1, 4
• Check for postural hypotension regularly when treating with BP-lowering drugs 1
• In elderly patients, use gradual escalation of treatment with close attention to adverse events including electrolyte disorders, acute deterioration in kidney function, and orthostatic hypotension 1