How should I manage chronic kidney disease (CKD) at each stage, including recommended drug therapy and treatment algorithm?

Management of Chronic Kidney Disease by Stage

All CKD patients with eGFR ≥20 mL/min/1.73 m² and either type 2 diabetes, albuminuria ≥200 mg/g, or heart failure should be started on an SGLT2 inhibitor immediately, and those with albuminuria >300 mg/g must receive maximum-tolerated ACE inhibitor or ARB therapy regardless of blood pressure. 1

Diagnostic Staging Framework

CKD staging requires simultaneous assessment of both eGFR and urine albumin-to-creatinine ratio (UACR) to accurately stratify risk and guide treatment intensity. 1

eGFR Categories (G1-G5):

• G1: ≥90 mL/min/1.73 m² (normal/high) 1
• G2: 60-89 mL/min/1.73 m² (mildly decreased) 1
• G3a: 45-59 mL/min/1.73 m² (mild-moderate) 1
• G3b: 30-44 mL/min/1.73 m² (moderate-severe) 1
• G4: 15-29 mL/min/1.73 m² (severe) 1
• G5: <15 mL/min/1.73 m² (kidney failure) 1

Albuminuria Categories (A1-A3):

• A1: <30 mg/g (normal-mild) 1
• A2: 30-300 mg/g (moderate) 1
• A3: >300 mg/g (severe) 1

Chronicity must be confirmed by repeating abnormal eGFR or albuminuria measurements after ≥3 months, or by reviewing prior labs showing reduced kidney size on imaging or pathology. 1

Stage-Specific Management Algorithm

Stage 1-2 (eGFR ≥60 mL/min/1.73 m²)

Primary focus is screening, risk factor modification, and treatment of comorbid conditions. 2

Monitoring Frequency:

• Annual assessment of UACR and eGFR for all patients with diabetes (type 1 ≥5 years duration, all type 2) and those with identified kidney damage. 2

Pharmacologic Therapy:

• ACE-I or ARB at maximum tolerated dose if UACR 30-299 mg/g (moderate albuminuria). 2
• ACE-I or ARB is mandatory if UACR ≥300 mg/g (severe albuminuria). 2, 1
• SGLT2 inhibitor for all patients with type 2 diabetes and eGFR ≥20 mL/min/1.73 m². 1
• SGLT2 inhibitor for patients with UACR ≥200 mg/g or heart failure, regardless of diabetes status. 1
• Statin therapy for all patients ≥50 years old. 1

Blood Pressure Targets:

• ≤140/90 mmHg if albuminuria <30 mg/24h. 3
• ≤130/80 mmHg if albuminuria ≥30 mg/24h. 2, 3
• Target systolic BP <120 mmHg when tolerated using standardized office measurement. 3

Stage 3a (eGFR 45-59 mL/min/1.73 m²)

Focus shifts to estimating progression rate and intensifying cardiovascular risk reduction. 2

Monitoring Frequency:

• Assess eGFR and UACR 1-2 times per year depending on albuminuria category. 2, 1

Pharmacologic Therapy:

• Continue or initiate ACE-I/ARB at maximum tolerated dose if any albuminuria present. 1
• SGLT2 inhibitor for type 2 diabetes, UACR ≥200 mg/g, or heart failure. 1
• Consider SGLT2 inhibitor even if UACR <200 mg/g. 1
• Statin or statin + ezetimibe for all patients ≥50 years. 1
• GLP-1 receptor agonist with proven cardiovascular benefit if type 2 diabetes not at glycemic target despite metformin and SGLT2i. 1

Additional Interventions:

• Optimize glucose control to HbA1c ≈7% in diabetic patients. 2, 3
• Sodium restriction to <2 g/day. 1, 3
• Maintain BMI 20-25 kg/m². 1

Stage 3b (eGFR 30-44 mL/min/1.73 m²)

Evaluate and treat complications of CKD while continuing progression-slowing therapies. 2

Monitoring Frequency:

• Assess eGFR and UACR 2-3 times per year. 2, 1, 3
• Monitor for anemia, bone-mineral disorders, metabolic acidosis, and hypertension. 2

Pharmacologic Therapy:

• Continue ACE-I/ARB even as eGFR declines below 30 mL/min/1.73 m²; do not discontinue based on eGFR alone. 1, 4
• Continue SGLT2 inhibitor; do not stop even if eGFR falls below 20 mL/min/1.73 m² after initiation. 1
• Add finerenone (non-steroidal MRA) if type 2 diabetes, eGFR >25 mL/min/1.73 m², normal potassium, and persistent albuminuria despite maximum ACE-I/ARB dose. 1
  • Finerenone 10 mg daily if eGFR 25-59 mL/min/1.73 m² and potassium ≤4.8 mmol/L. 1
  • Monitor potassium at 1 month, then every 4 months. 1
• Oral bicarbonate supplementation if serum bicarbonate <22 mmol/L to maintain normal range. 3

Critical Medication Considerations:

• Never prescribe NSAIDs at this stage—they significantly increase acute kidney injury risk and accelerate CKD progression. 3
• Adjust all renally cleared medication doses based on eGFR. 2

Stage 4 (eGFR 15-29 mL/min/1.73 m²)

Prepare for kidney replacement therapy while managing complications. 2

Monitoring Frequency:

• Assess eGFR and UACR 3-4 times per year. 2, 1
• Monitor hemoglobin, calcium, phosphorus, PTH, and bicarbonate regularly. 2

Pharmacologic Therapy:

• Continue ACE-I/ARB unless symptomatic hypotension, refractory hyperkalemia despite medical management, or uremic symptoms develop. 1, 4
• Continue SGLT2 inhibitor unless not tolerated or kidney replacement therapy initiated. 1
• Finerenone contraindicated if eGFR ≤25 mL/min/1.73 m². 1
• Loop diuretics preferred over thiazides for volume management. 4

Hyperkalemia Management Strategy:

• Do not automatically stop ACE-I/ARB for hyperkalemia; first attempt dietary potassium restriction, diuretics, and potassium binders. 1, 4
• Discontinue ACE-I/ARB only if potassium remains uncontrolled despite these measures. 1, 4

Preparation for Kidney Replacement:

• Refer to nephrology for dialysis access planning and transplant evaluation. 2
• Educate about dialysis modalities and transplantation options. 2

Stage 5 (eGFR <15 mL/min/1.73 m²)

Initiate kidney replacement therapy if uremic symptoms present. 2

Management:

• Continue ACE-I/ARB only if no uremic symptoms, symptomatic hypotension, or refractory hyperkalemia. 1
• Discontinue SGLT2 inhibitor once kidney replacement therapy initiated. 1
• Avoid gadolinium-containing contrast unless no alternative exists. 3

Critical Monitoring Parameters for All Stages

After ACE-I/ARB Initiation or Dose Adjustment:

• Check blood pressure, serum creatinine, and potassium within 2-4 weeks. 1, 4
• Discontinue only if serum creatinine rises >30% within 4 weeks of initiation or dose increase. 1, 4
• A rise up to 30% is acceptable and expected. 1

After SGLT2 Inhibitor Initiation:

• A modest, reversible eGFR dip is hemodynamic and not a reason to discontinue therapy. 1
• Withhold during prolonged fasting, surgery, or critical illness due to ketoacidosis risk. 1, 4

Progression Monitoring:

• Progression is defined by both a change in eGFR category AND a ≥25% decline in eGFR to prevent misinterpretation of small fluctuations. 1

Universal Lifestyle Interventions (All Stages)

• Sodium restriction to <2 g/day. 1, 3
• Protein intake 0.8 g/kg body weight/day for stages G3-G5. 3
• Target BMI 20-25 kg/m². 1
• Smoking cessation. 1
• Aerobic exercise ≥150 minutes per week. 1, 3
• Plant-based Mediterranean-style diet. 1

Common Pitfalls to Avoid

• Do not discontinue ACE-I/ARB solely because eGFR falls below 30 mL/min/1.73 m²; continue unless specific contraindications arise. 1, 4
• Do not stop SGLT2 inhibitor for initial eGFR dip; this is expected and reversible. 1
• Do not diagnose progression on minor eGFR changes that merely cross category thresholds without ≥25% decline. 1
• Do not prescribe NSAIDs in stage 3b or higher. 3
• Do not forget to restart ACE-I/ARB, ARB, and SGLT2i after temporary discontinuation for surgery or acute illness—failure to restart causes unintentional harm. 2