What are the recommended clinical management steps for a patient with chronic kidney disease?

Clinical Management of Chronic Kidney Disease

All patients with CKD should receive a comprehensive treatment strategy that includes SGLT2 inhibitors, RAS inhibitors, blood pressure control, statin therapy, and lifestyle modifications, with the specific interventions tailored to CKD stage and comorbidities. 1

Risk Stratification and Monitoring

Initial Assessment

• Use externally validated risk equations to estimate absolute risk of kidney failure in CKD G3-G5 patients 1
• Calculate 5-year kidney failure risk: ≥3-5% threshold determines need for nephrology referral 1
• Calculate 2-year kidney failure risk: >10% triggers multidisciplinary care planning, >40% initiates dialysis preparation and transplant evaluation 1
• Estimate 10-year cardiovascular risk using validated tools that incorporate eGFR and albuminuria 1

Disease-Specific Risk Tools

• Use IgA nephropathy-specific equations for IgAN patients 1
• Use ADPKD-specific equations for polycystic kidney disease 1

Pharmacologic Management

Foundation Therapy: SGLT2 Inhibitors and RAS Blockade

SGLT2 inhibitors should be initiated in all CKD patients with or without diabetes to reduce progression and cardiovascular events 1

• Start RAS inhibitors (ACE inhibitors or ARBs) in patients with albuminuria, diabetes, or heart failure 1, 2
• Continue RAS inhibitors despite modest increases in serum creatinine or potassium unless contraindicated 1

Advanced Therapy: Nonsteroidal MRA

Add finerenone to RASi + SGLT2i in patients with type 2 diabetes and persistent albuminuria 1

Finerenone Dosing Algorithm: 1

• Potassium ≤4.8 mmol/L: Initiate 10 mg daily (eGFR 25-59) or 20 mg daily (eGFR ≥60)
• Potassium 4.9-5.5 mmol/L: Continue current dose, monitor every 4 months
• Potassium >5.5 mmol/L: Hold medication, adjust diet/medications, recheck potassium, restart at 10 mg when ≤5.0 mmol/L

Critical Monitoring: Check potassium at 1 month after initiation, then every 4 months 1

GLP-1 Receptor Agonists

• Add long-acting GLP-1 RA in T2D patients not at glycemic target despite metformin and SGLT2i 1
• Prioritize agents with documented cardiovascular benefits 1

Cardiovascular Risk Management

Lipid Management

All adults ≥50 years with eGFR <60 should receive statin or statin/ezetimibe combination 1

• Adults ≥50 with eGFR ≥60: statin monotherapy 1
• Adults 18-49: statin if coronary disease, diabetes, prior stroke, or 10-year MI risk >10% 1
• Maximize LDL reduction to achieve largest treatment benefit 1
• Consider PCSK-9 inhibitors when indicated 1

Antiplatelet Therapy

• Low-dose aspirin for secondary prevention in established ischemic cardiovascular disease 1
• Consider P2Y12 inhibitors if aspirin intolerant 1

Atrial Fibrillation Management

• Use NOACs (not warfarin) for thromboprophylaxis in CKD G1-G4 1
• Dose-adjust NOACs based on eGFR, exercise caution in G4-G5 1

Metabolic Complications Management

Metabolic Acidosis

• Consider pharmacologic treatment ± dietary intervention when bicarbonate <18 mmol/L 1
• Monitor to prevent bicarbonate exceeding normal range and adverse effects on BP, potassium, or fluid status 1

Hyperkalemia Management

Implement individualized dietary and pharmacologic approach in CKD G3-G5 1

• Limit bioavailable potassium foods (especially processed foods) in patients with hyperkalemia history 1
• Be aware of potassium measurement variability (diurnal, seasonal, plasma vs serum) 1
• Involve renal dietitian for assessment and education 1

Hyperuricemia and Gout

• Offer uric acid-lowering therapy for symptomatic hyperuricemia 1
• Consider initiating after first gout episode, especially if uric acid >9 mg/dL 1
• Prescribe xanthine oxidase inhibitors (not uricosuric agents) 1
• Do NOT treat asymptomatic hyperuricemia to delay CKD progression 1

Acute Gout Treatment: Use low-dose colchicine or glucocorticoids; avoid NSAIDs due to nephrotoxicity 1

Lifestyle Modifications

Physical Activity

Recommend moderate-intensity physical activity for ≥150 minutes per week 1

• Adjust intensity based on cardiovascular tolerance, frailty risk, and fall risk 1
• Advise against sedentary behavior 1
• Consider weight loss in obese patients 1

Dietary Interventions

• Mediterranean-style plant-based diet for cardiovascular risk reduction 1
• Limit alcohol, meats, and high-fructose corn syrup to prevent gout 1
• Individualized sodium restriction for blood pressure control 1

Critical Pitfalls to Avoid

Never prescribe NSAIDs in CKD patients - they cause acute kidney injury, worsen heart failure, and accelerate progression 3, 4

• Do not discontinue RAS inhibitors for modest creatinine or potassium elevations without careful assessment 1
• Avoid iodinated contrast in advanced CKD; use iso-osmolar agents when necessary 3
• Do not assume single cause of complications - investigate comprehensively (e.g., anemia may have multiple CKD-related causes) 3
• Monitor potassium variability before making medication changes 1

Nephrology Referral Criteria

• 5-year kidney failure risk ≥3-5% 1
• Rapidly declining eGFR 1
• Poorly controlled hypertension despite treatment 1
• Suspected inherited kidney disease 1
• Persistent significant proteinuria 1