How should chronic kidney disease be evaluated and managed, including staging, blood pressure targets, medication choices (ACE inhibitor/ARB, SGLT2 inhibitor, etc.), glycemic control, dietary measures, monitoring for complications, and referral criteria?

Chronic Kidney Disease: Evaluation and Management

First-Line Foundational Therapy

Initiate SGLT2 inhibitors immediately as mandatory first-line therapy for all CKD patients with eGFR ≥20 mL/min/1.73 m², regardless of diabetes status, using dapagliflozin 10 mg daily or canagliflozin 100 mg daily. 1 Continue SGLT2 inhibitors even as eGFR declines below 20 mL/min/1.73 m² until dialysis initiation or transplantation. 1

CKD Staging and Surveillance

Initial Assessment

• Measure both eGFR and urine albumin-to-creatinine ratio (UACR) to stage CKD and assess progression risk. 2
• Stage CKD using the KDIGO classification system based on GFR categories (G1-G5) and albuminuria categories (A1-A3). 2

Monitoring Frequency

• Stage G1-G2 (eGFR ≥60): Monitor annually 2
• Stage G3a-G3b (eGFR 30-59): Monitor every 6-12 months 2
• Stage G4 (eGFR 15-29): Monitor every 3-5 months 2
• Stage G5 (eGFR <15): Monitor every 1-3 months 2
• Higher albuminuria categories require more frequent monitoring regardless of GFR. 2

Defining Progression

• CKD progression requires both a change in GFR category AND ≥25% decrease in eGFR to avoid misinterpreting small fluctuations. 2, 3

Blood Pressure Management

Target Blood Pressure

• With albuminuria ≥30 mg/24 hours: Target BP ≤130/80 mmHg 2, 1
• With albuminuria <30 mg/24 hours: Target BP ≤140/90 mmHg 2, 3
• Optimal target is systolic BP <120 mmHg for most patients when tolerated. 2

Medication Selection

• ACE inhibitors or ARBs: First-line for patients with albuminuria ≥30 mg/24 hours, titrated to maximum tolerated dose 2, 1, 4
• Mandatory for albuminuria ≥300 mg/24 hours (macroalbuminuria) in both diabetic and non-diabetic patients 2, 4
• Do NOT use ACE inhibitors or ARBs for primary prevention in patients with normal BP and normal albumin excretion (<30 mg/g). 4
• Add dihydropyridine calcium channel blockers and/or diuretics if additional agents needed to reach BP target. 2

Monitoring on RAS Inhibitors

• Monitor serum potassium periodically in patients with eGFR <60 mL/min/1.73 m² receiving ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists. 2

Advanced Kidney Protection

Nonsteroidal Mineralocorticoid Receptor Antagonists

• Add finerenone for patients with diabetic kidney disease already on RAS inhibition for additive kidney and cardiovascular protection. 2, 1, 3

Steroidal MRAs

• Use steroidal mineralocorticoid receptor antagonists for resistant hypertension management. 2

Glycemic Control in Diabetic CKD

Target HbA1c

• Maintain HbA1c at approximately 7% to reduce risk and slow CKD progression. 2, 4

Medication Selection

• SGLT2 inhibitors: First-line for both glycemic control and kidney protection in diabetic CKD 1, 4
• GLP-1 receptor agonists: Consider for additional cardiovascular risk reduction and albuminuria reduction 2, 4
• Metformin: Acceptable if eGFR ≥30 mL/min/1.73 m², but AVOID when eGFR <30 mL/min/1.73 m² 1
• AVOID sulfonylureas due to increased hypoglycemia risk 1

Therapeutic Target

• Aim for ≥30% reduction in urinary albumin as a therapeutic target to slow CKD progression. 4

Cardiovascular Risk Reduction

Statin Therapy

• Mandatory for all CKD patients ≥50 years: Use moderate-to-high intensity statin (atorvastatin 40-80 mg daily or rosuvastatin 20-40 mg daily) 2, 1, 3
• Continue statins until dialysis or transplantation. 2
• Consider ezetimibe or PCSK9 inhibitors based on ASCVD risk and lipid levels. 2

Antiplatelet Therapy

• Aspirin 81 mg daily for lifelong secondary prevention in CKD patients with established cardiovascular disease 1

Dietary Management

Protein Intake

• 0.8 g/kg body weight per day (the recommended daily allowance) for non-dialysis-dependent CKD 2, 1, 4
• Do NOT reduce below 0.8 g/kg/day as it does not alter outcomes 2
• AVOID high-protein intake (>20% of daily calories or >1.3 g/kg/day) as it accelerates kidney function loss 2
• Do NOT restrict protein in patients who are cachexic, sarcopenic, or undernourished. 2

Sodium Restriction

• <2 g per day (<2,300 mg/day) to control blood pressure and reduce cardiovascular risk 2, 1, 4

Weight Management

• Target BMI 20-25 kg/m² 2, 1

Dietary Pattern

• Encourage plant-based diets and Mediterranean-style diet to reduce cardiovascular risk. 2, 3

Lifestyle Modifications

• Physical activity: 30 minutes of exercise 5 times per week compatible with cardiovascular health and frailty level 2
• Smoking cessation: Mandatory for all CKD patients 2

Monitoring for CKD Complications

When eGFR Falls Below 60 mL/min/1.73 m²

Monitor for the following complications every 3-6 months: 2, 1

Anemia

• Check hemoglobin regularly 2
• Treat with iron supplementation before or with erythropoiesis-stimulating agents 1
• Assess iron, iron saturation, and ferritin if indicated 2

Metabolic Bone Disease (CKD-MBD)

• Monitor serum calcium, phosphate, parathyroid hormone, and vitamin 25(OH)D 2

Metabolic Acidosis

• Check serum electrolytes and bicarbonate 2
• Treat when bicarbonate <18 mmol/L to prevent anorexia, protein wasting, and bone disease 2

Electrolyte Abnormalities

• Monitor serum potassium, especially in patients on diuretics, ACE inhibitors, ARBs, or MRAs 2
• Individualize dietary potassium based on serum levels; avoid highly processed foods but do NOT restrict fruits and vegetables 2

Volume Overload

• Assess at every clinical contact through history, physical examination, and weight 2

Hyperuricemia

• Do NOT treat asymptomatic hyperuricemia; only treat if symptomatic (gout or tophi) 2

Medications to AVOID in CKD

• NSAIDs: Increased risk of acute kidney injury 2, 1
• Metformin when eGFR <30 mL/min/1.73 m²: Risk of lactic acidosis 1
• Sulfonylureas: Increased hypoglycemia risk 1
• Iodinated contrast: Minimize exposure, especially when eGFR <60 mL/min/1.73 m² 2

Medication Dosing Adjustments

• Verify medication dosing for all patients with eGFR <60 mL/min/1.73 m², including antibiotics and oral hypoglycemic agents. 2, 5

Nephrology Referral Criteria

Immediate Referral Required When:

• eGFR <30 mL/min/1.73 m² 1, 4, 5
• Persistent electrolyte abnormalities despite treatment 1
• Uncontrolled hypertension despite multiple agents 1, 3
• Uncertainty about kidney disease etiology 3
• Significant albuminuria increases despite good BP control 3
• Rapid decline in eGFR 5
• Albuminuria ≥300 mg per 24 hours 5

Regular Reassessment Schedule

Every 3-6 months, assess: 2, 1

• eGFR and serum creatinine
• Electrolytes (sodium, potassium, bicarbonate)
• Urine albumin-to-creatinine ratio
• Hemoglobin
• Blood pressure
• Lipid panel

Common Pitfalls to Avoid

• Do NOT withhold ACE inhibitors/ARBs for small increases in serum creatinine or potassium unless clinically significant 2
• Do NOT combine ACE inhibitors with ARBs; insufficient evidence for benefit and increased risk of adverse events 2
• Do NOT delay SGLT2 inhibitor initiation; it is foundational therapy regardless of diabetes status 1
• Do NOT restrict dietary protein below 0.8 g/kg/day 2
• Do NOT interpret small GFR fluctuations as progression without meeting both criteria (category change AND ≥25% decrease) 2, 3