What is the appropriate prescription and management plan for a patient with Chronic Kidney Disease (CKD), hypertension, and possibly diabetes, in an outpatient department (OPD) setting?

OPD Follow-Up Prescription for CKD Patients

All CKD patients require SGLT2 inhibitors as mandatory first-line therapy when eGFR ≥20 mL/min/1.73 m², combined with RAS blockade (if hypertensive with albuminuria), statin therapy, and regular monitoring every 3-6 months. 1, 2

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Core Medication Regimen

First-Line Therapy (Start Immediately)

SGLT2 Inhibitor (mandatory for all CKD patients, regardless of diabetes status):

• Dapagliflozin 10 mg PO daily OR Canagliflozin 100 mg PO daily 1, 2, 3
• Continue until dialysis or transplantation, even as eGFR declines below 20 mL/min/1.73 m² 2, 4
• Provides kidney protection, cardiovascular benefits, and reduces heart failure hospitalizations independent of glucose-lowering effects 3

RAS Inhibitor (if hypertensive AND albuminuria ≥30 mg/g):

• Losartan 50-100 mg PO daily OR Lisinopril 10-40 mg PO daily 1
• Titrate to maximum tolerated dose for optimal kidney and cardiovascular protection 1, 3
• Monitor serum creatinine and potassium within 2-4 weeks after initiation or dose changes 1, 3
• Continue unless creatinine rises >30% within 4 weeks 4
• Never combine ACE inhibitor with ARB - this increases harm without benefit 1, 3

Statin Therapy (for all CKD patients):

• Atorvastatin 40-80 mg PO daily OR Rosuvastatin 20-40 mg PO daily 1, 2, 4
• Mandatory for all diabetic CKD patients and all CKD patients ≥50 years 2, 4
• Target LDL-C <100 mg/dL (consider <70 mg/dL for very high cardiovascular risk) 4

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Blood Pressure Management

Target Blood Pressure:

• <130/80 mmHg for all CKD patients with albuminuria ≥30 mg/g 1, 3, 4
• <140/90 mmHg if albuminuria <30 mg/g 4
• Aim for systolic BP <120 mmHg when tolerated 1

Additional Antihypertensive Agents (if BP target not achieved):

• Amlodipine 5-10 mg PO daily (dihydropyridine calcium channel blocker) 1, 4
• Chlorthalidone 12.5-25 mg PO daily OR Furosemide 20-40 mg PO daily (diuretic) 1
• All three classes (RAS inhibitor, CCB, diuretic) are often needed to attain BP targets 1

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Diabetes Management (if applicable)

Glycemic Control Target:

• HbA1c 6.5-8.0% (individualized based on hypoglycemia risk, life expectancy, comorbidities) 3, 4
• Check HbA1c every 3 months when adjusting therapy, at least twice yearly when stable 3, 4

Glucose-Lowering Medications:

• Metformin 500-1000 mg PO twice daily (if eGFR ≥30 mL/min/1.73 m²) 3, 4
  • Reduce to 1000 mg daily total when eGFR 30-44 mL/min/1.73 m² 4
  • Discontinue when eGFR <30 mL/min/1.73 m² due to lactic acidosis risk 2, 4
• GLP-1 RA (e.g., Semaglutide 0.5-1 mg SC weekly) if SGLT2i/metformin insufficient or not tolerated 1, 4

Advanced Kidney Protection (if persistent albuminuria ≥30 mg/g despite first-line therapy):

• Finerenone 10-20 mg PO daily (nonsteroidal mineralocorticoid receptor antagonist) 1, 2, 4
• Only if potassium is normal 1, 4
• Provides additive kidney and cardiovascular protection beyond SGLT2i and RAS blockade 2, 4

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Cardiovascular Protection

Antiplatelet Therapy (if established cardiovascular disease):

• Aspirin 81 mg PO daily for lifelong secondary prevention 1, 2
• May be considered for primary prevention in high ASCVD risk patients 1

Additional Lipid Management (if LDL-C remains elevated):

• Ezetimibe 10 mg PO daily 1
• PCSK9 inhibitor (e.g., Evolocumab 140 mg SC every 2 weeks) if indicated based on ASCVD risk 1

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Lifestyle Modifications (Mandatory)

• Sodium restriction to <2 g per day (<90 mmol/day or <5 g sodium chloride/day) 1, 2, 3, 4
• Protein intake 0.8 g/kg body weight per day for non-dialysis CKD patients 1, 3, 4
• Target BMI 20-25 kg/m² through weight management 2
• Moderate-intensity physical activity ≥150 minutes per week 3, 4
• Tobacco cessation (mandatory for all tobacco users) 1, 4

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Monitoring Schedule

Every 3-6 Months:

• Serum creatinine and eGFR 1, 2, 3
• Electrolytes (sodium, potassium, bicarbonate) 2, 3
• Urine albumin-to-creatinine ratio 2, 3
• Hemoglobin (for anemia screening) 2
• Blood pressure 2, 3
• Lipid panel 2
• HbA1c (if diabetic) 3, 4

More Frequent Monitoring (every 1-6 months) if:

• eGFR <60 mL/min/1.73 m² 4
• GFR decline ≥4 mL/min/1.73 m²/year 4
• Recent medication changes (especially RAS inhibitors) 1, 3

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CKD Complications Management

Anemia (when eGFR <60 mL/min/1.73 m²):

• Monitor hemoglobin regularly 2, 4
• Iron supplementation before or with erythropoiesis-stimulating agents 2

Hyperkalemia:

• Attempt dietary modification, diuretics, sodium bicarbonate, or GI cation exchangers before discontinuing RAS blockade 4

Metabolic Acidosis, CKD-MBD, Electrolyte Disturbances:

• Manage as indicated when eGFR <60 mL/min/1.73 m² 1, 4

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Nephrology Referral Criteria

Immediate Referral When:

• eGFR <30 mL/min/1.73 m² (Stage 4 CKD) 2, 3, 4
• Persistent electrolyte abnormalities despite management 2
• Uncontrolled hypertension despite multiple agents 2
• Albuminuria ≥300 mg/g despite treatment 4
• Rapidly declining kidney function 4
• Uncertainty about CKD etiology 4

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Critical Medications to AVOID

• NSAIDs - increased acute kidney injury risk 2
• Metformin when eGFR <30 mL/min/1.73 m² - lactic acidosis risk 2, 4
• Sulfonylureas - increased hypoglycemia risk 2
• ACE inhibitor + ARB combination - increased harm without benefit 1, 3

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Common Pitfalls

• Do not delay SGLT2 inhibitor initiation - it should be started immediately when eGFR ≥20 mL/min/1.73 m², regardless of diabetes status or glycemic control 2, 3
• Do not discontinue RAS inhibitors for mild creatinine elevation (<30% rise within 4 weeks is acceptable) 4
• Do not overlook cardiovascular disease management - CKD patients are more likely to have cardiovascular events than progress to end-stage renal disease 3
• Do not restrict protein in cachexic, sarcopenic, or undernourished patients 1
• Monitor for acute kidney injury - all CKD patients are at increased risk, especially during volume depletion or nephrotoxin exposure 1, 4