What medications are recommended for a patient with chronic kidney disease (CKD) and impaired renal function, characterized by a glomerular filtration rate (GFR) below 60 mL/min/1.73m^2?

Medications for Chronic Kidney Disease with GFR <60 mL/min/1.73m²

Core Pharmacotherapy for CKD Stage 3-5

For patients with CKD and eGFR <60 mL/min/1.73m², statin therapy is the single most important medication to initiate immediately, followed by SGLT2 inhibitors and ACE inhibitors/ARBs based on specific clinical criteria. 1

Cardiovascular Protection: Statins (Highest Priority)

All adults ≥50 years with eGFR <60 mL/min/1.73m² must receive a statin or statin/ezetimibe combination regardless of cholesterol levels. 1

• This is a Class 1A recommendation—the strongest level of evidence available 1
• Choose high-intensity statins to maximize absolute LDL reduction for greatest treatment benefit 1
• For adults 18-49 years, initiate statins if they have coronary disease, diabetes, prior stroke, or 10-year cardiovascular risk >10% 1
• Consider adding ezetimibe to statin therapy for additional cardiovascular risk reduction 1
• PCSK-9 inhibitors should be considered for patients with CKD who have standard indications for their use 1

Kidney Protection: SGLT2 Inhibitors

For patients with type 2 diabetes and CKD with eGFR ≥20 mL/min/1.73m² and albuminuria ≥200 mg/g, initiate an SGLT2 inhibitor (dapagliflozin 10 mg daily or empagliflozin) immediately. 1

• This provides 39% reduction in kidney disease progression and 29% reduction in cardiovascular death or heart failure hospitalization 2
• SGLT2 inhibitors work independently of glucose control—their primary benefit is cardiorenal protection, not glycemic management 1, 2
• For eGFR 20-44 mL/min/1.73m², continue SGLT2 inhibitors at 10 mg daily for cardiovascular/renal protection even though glucose-lowering efficacy is minimal 2
• Do not initiate SGLT2 inhibitors if eGFR <20 mL/min/1.73m², but if already on therapy, continue until dialysis 2
• For patients with albuminuria <200 mg/g but ≥30 mg/g, SGLT2 inhibitors are still recommended if eGFR ≥20 mL/min/1.73m² 1

Critical SGLT2 inhibitor safety considerations:

• Withhold during acute illness (fever, vomiting, diarrhea, reduced oral intake) to prevent diabetic ketoacidosis and volume depletion 2
• Stop at least 3 days before major surgery or prolonged fasting 2
• Monitor for genital mycotic infections (6% incidence) and educate patients on euglycemic DKA risk 2
• Expect transient eGFR dip of 3-5 mL/min/1.73m² in first 1-4 weeks—this is hemodynamic and reversible, not harmful 2

Blood Pressure Control: ACE Inhibitors or ARBs

For patients with albuminuria ≥30 mg/g and eGFR <60 mL/min/1.73m², prescribe either an ACE inhibitor or ARB (not both). 1

• For albuminuria 30-299 mg/g: ACE inhibitor or ARB is recommended (Class 1B) 1
• For albuminuria ≥300 mg/g: ACE inhibitor or ARB is strongly recommended (Class 1A) 1
• Do not combine ACE inhibitors with ARBs—this increases adverse events (hyperkalemia, acute kidney injury) without additional benefit 1
• Do not discontinue for serum creatinine increases ≤30% unless volume depletion is present 1
• Monitor potassium and creatinine within 1-2 weeks after initiation, then periodically 1

ACE inhibitor/ARB dosing in CKD:

• Lisinopril: No dose adjustment needed until eGFR <30 mL/min/1.73m² 3
• Enalapril: No specific dose adjustment for mild-moderate CKD; monitor closely 4
• Valsartan: No dose adjustment for eGFR 30-60 mL/min/1.73m²; not studied in eGFR <30 mL/min/1.73m² 5

Glucose Management in Diabetic CKD

Metformin remains first-line for glycemic control if eGFR ≥30 mL/min/1.73m². 1

• Continue metformin at full dose if eGFR ≥60 mL/min/1.73m² 1
• Reduce metformin to half maximum dose if eGFR 45-59 mL/min/1.73m² 1
• Reduce metformin to maximum 1000 mg/day if eGFR 30-44 mL/min/1.73m² 1
• Stop metformin if eGFR <30 mL/min/1.73m² 1
• Monitor eGFR at least every 3-6 months if eGFR 45-59 mL/min/1.73m², annually if ≥60 mL/min/1.73m² 1

For additional glucose control beyond metformin and SGLT2 inhibitors, GLP-1 receptor agonists are preferred. 1

• GLP-1 RAs reduce cardiovascular events and may slow CKD progression 1
• They have low hypoglycemia risk and promote weight loss 1
• Consider GLP-1 RAs particularly if eGFR <45 mL/min/1.73m² where SGLT2 inhibitor glucose-lowering efficacy is reduced 1, 2

Additional Kidney-Protective Medications

Nonsteroidal mineralocorticoid receptor antagonists (finerenone) for patients with type 2 diabetes, CKD, and albuminuria ≥30 mg/g who remain at high risk despite SGLT2 inhibitors and ACE inhibitors/ARBs. 1

• Finerenone reduces CKD progression and cardiovascular events 1
• Monitor potassium closely—this is the primary safety concern 1
• Use only if potassium is normal at baseline 1

Antiplatelet Therapy

Low-dose aspirin (75-100 mg daily) for secondary prevention in patients with established cardiovascular disease. 1

• This is Class 1C recommendation for patients with prior MI, stroke, or coronary revascularization 1
• Consider P2Y12 inhibitors if aspirin intolerance 1
• Do not use aspirin for primary prevention in CKD without established cardiovascular disease 1

Management of Hyperuricemia and Gout

Treat symptomatic hyperuricemia (gout) with xanthine oxidase inhibitors (allopurinol or febuxostat), not uricosuric agents. 1

• Initiate uric acid-lowering therapy after first gout episode, especially if uric acid >9 mg/dL 1
• For acute gout flares: use low-dose colchicine or glucocorticoids (oral or intra-articular)—avoid NSAIDs in CKD 1
• Do not treat asymptomatic hyperuricemia—it does not slow CKD progression 1

Dietary Protein Restriction

Limit dietary protein to maximum 0.8 g/kg/day for non-dialysis CKD stage 3 or higher. 1

• This is the recommended daily allowance, not a reduction below normal 1
• Higher protein intake is needed for patients on dialysis to prevent malnutrition 1

Medications to Avoid or Use with Extreme Caution

NSAIDs should be avoided in CKD as they worsen renal function and increase cardiovascular risk. 1, 4

• NSAIDs can cause acute kidney injury, particularly in elderly or volume-depleted patients 4
• They may blunt the antihypertensive effects of ACE inhibitors and ARBs 4
• For pain management, consider acetaminophen or low-dose opioids with appropriate dose adjustments 6

Potassium supplements and salt substitutes containing potassium require careful monitoring. 1, 4

• Risk of hyperkalemia increases with ACE inhibitors/ARBs, mineralocorticoid receptor antagonists, and reduced kidney function 1, 4
• Monitor potassium levels regularly when using these combinations 1

Monitoring Requirements

For CKD stage 3a-3b (eGFR 30-59 mL/min/1.73m²): Monitor eGFR and albuminuria every 3-6 months. 1

For CKD stage 4-5 (eGFR <30 mL/min/1.73m²): Monitor eGFR and albuminuria every 1-3 months. 1

• Check potassium, bicarbonate, phosphate, and hemoglobin regularly to screen for CKD complications 7
• Reassess cardiovascular risk annually using validated risk tools 1

Common Pitfalls to Avoid

Do not discontinue SGLT2 inhibitors when eGFR falls below 45 mL/min/1.73m²—cardiovascular and renal benefits persist even when glucose-lowering efficacy is lost 2

Do not withhold ACE inhibitors/ARBs for creatinine increases ≤30% unless volume depletion is present—small increases are expected and hemodynamic 1

Do not combine ACE inhibitors with ARBs—dual RAS blockade increases harm without benefit 1, 4

Do not delay statin initiation—this is the single most important medication for reducing mortality in CKD 1

Do not continue metformin if eGFR <30 mL/min/1.73m²—risk of lactic acidosis increases significantly 1