What is the recommended prevention, screening, and treatment strategy for chronic kidney disease across all age groups, including medication choices, dietary measures, and criteria for dialysis or transplantation?

Comprehensive Management of Chronic Kidney Disease Across All Ages

All individuals at risk for chronic kidney disease should be screened using both urine albumin measurement and estimated glomerular filtration rate (eGFR), with treatment prioritizing blood pressure control, renin-angiotensin system inhibition for albuminuria, SGLT2 inhibitors for diabetic kidney disease, and dietary modifications tailored to age and comorbidities. 1

Screening and Detection

Who Should Be Screened

• Screen adults with diabetes, hypertension, cardiovascular disease, age ≥60 years, family history of kidney disease, or history of acute kidney injury 1, 2
• Test using both urine albumin-to-creatinine ratio (UACR) and eGFR calculation 1
• For type 1 diabetes, begin screening after 5 years of disease duration; for type 2 diabetes, screen at diagnosis 1
• Annual screening with ambulatory blood pressure monitoring in children with CKD 1

Diagnostic Criteria

• CKD is defined as kidney damage (albuminuria ≥30 mg/g creatinine) or eGFR <60 mL/min/1.73 m² persisting for ≥3 months 1
• Stage kidney disease by eGFR: Stage 1 (≥90), Stage 2 (60-89), Stage 3a (45-59), Stage 3b (30-44), Stage 4 (15-29), Stage 5 (<15 mL/min/1.73 m²) 1

Blood Pressure Management

Target Blood Pressure

• Target systolic BP <120 mm Hg using standardized office measurement in adults with CKD when tolerated 1
• For patients with diabetes and high cardiovascular risk (≥15% 10-year ASCVD risk), target <130/80 mm Hg 1
• In children with CKD, target 24-hour mean arterial pressure ≤50th percentile for age, sex, and height using ambulatory monitoring 1

Special Populations Requiring Modified Targets

• Use less intensive BP lowering in patients with frailty, high fall risk, very limited life expectancy, or symptomatic postural hypotension 1, 3
• Older adults with these conditions may tolerate systolic BP targets closer to 130-140 mm Hg 3

Pharmacologic Treatment

Renin-Angiotensin System Inhibition

• Start ACE inhibitor or ARB for adults with CKD stages G1-G4 and severely increased albuminuria (A3, ≥300 mg/g) without diabetes 1
• For diabetic kidney disease with moderately increased albuminuria (30-299 mg/g), use ACE inhibitor or ARB 1
• Do NOT use RAS inhibitors for primary prevention in diabetic patients with normal BP and albuminuria <200 mg/g 1
• Monitor BP, serum creatinine, and potassium within 2-4 weeks of initiation or dose increase 3
• Accept serum creatinine increases up to 30% without discontinuing therapy if no volume depletion present 1

SGLT2 Inhibitors

• Use SGLT2 inhibitors in type 2 diabetes with diabetic kidney disease when eGFR ≥20 mL/min/1.73 m² to reduce CKD progression and cardiovascular events 1
• This applies across the full albuminuria spectrum from normal to severely increased 1
• Continue metformin when eGFR ≥30 mL/min/1.73 m² and adjust dose when eGFR falls below this threshold 1

Additional Cardiovascular Protection

• Prescribe moderate-intensity statin for all adults with CKD aged 40-75 years; use high-intensity statin for secondary prevention of ASCVD 1, 3
• Consider GLP-1 receptor agonist or nonsteroidal mineralocorticoid receptor antagonist (when eGFR ≥25 mL/min/1.73 m²) for additional cardiovascular risk reduction in type 2 diabetes 1

Dietary Management

Protein Intake

• Maintain protein intake at 0.8 g/kg/day in adults with CKD stages G3-G5 1
• Avoid high protein intake >1.3 g/kg/day in adults at risk of progression 1
• In motivated adults at high risk of kidney failure, consider very low-protein diet (0.3-0.4 g/kg/day) supplemented with essential amino acids or ketoacid analogs under close supervision 1, 4
• Never restrict protein in children with CKD—target upper end of normal range to promote optimal growth 1
• In older adults with frailty or sarcopenia, increase protein above 0.8 g/kg/day and provide higher calorie targets 1, 3, 4

Sodium Restriction

• Restrict sodium to <2 g/day (<90 mmol/day or <5 g sodium chloride/day) 1, 3, 5
• Exception: Do not restrict sodium in patients with sodium-wasting nephropathy 1, 5
• Use age-based recommendations for children with CKD and elevated BP 1

Dietary Pattern

• Emphasize plant-based foods over animal-based foods and minimize ultraprocessed foods 1, 3
• Use renal dietitians to educate patients about sodium, phosphorus, potassium, and protein adaptations tailored to CKD severity 1, 5

Lifestyle Modifications

Physical Activity

• Encourage adults with CKD to undertake regular physical activity while avoiding sedentary behavior 1, 3
• Children with CKD should aim for 60 minutes of daily physical activity per WHO guidelines 1
• Provide specific guidance on exercise intensity and type for older adults at higher fall risk 3

Weight Management

• Advise adults with obesity and CKD to lose weight 1
• Encourage children with CKD to achieve and maintain healthy weight 1

Monitoring and Complications

Monitoring Schedule

• Monitor eGFR and albuminuria at least annually in early CKD 1
• Increase monitoring frequency as CKD progresses and in young adults transitioning from pediatric care 1
• Check for complications including hyperkalemia, metabolic acidosis, hyperphosphatemia, vitamin D deficiency, secondary hyperparathyroidism, and anemia 6

Nephrology Referral Criteria

• Refer when eGFR <30 mL/min/1.73 m² or albuminuria ≥300 mg/g with continuously increasing levels or decreasing eGFR 1
• Promptly refer for uncertain etiology, difficult management issues, or rapidly progressing disease 1
• Consider planning for preemptive transplantation and/or dialysis access when eGFR <15-20 mL/min/1.73 m² or 2-year KRT risk >40% 1

Dialysis Initiation

Timing Criteria

• Initiate dialysis based on composite assessment of symptoms, signs, quality of life, preferences, GFR level, and laboratory abnormalities—typically when eGFR is 5-10 mL/min/1.73 m² 1
• Specific indications include uremic symptoms (neurological signs, pericarditis, anorexia), medically resistant electrolyte/acid-base abnormalities, inability to control volume status or BP, progressive nutritional deterioration, or cognitive impairment 1
• In children, poor growth refractory to optimized nutrition and growth hormone is an additional indication for dialysis 1

Transplantation

• Pursue preemptive kidney transplantation as treatment of choice for children with progressive irreversible CKD, typically when eGFR is 5-15 mL/min/1.73 m² 1
• Inform all patients about options for kidney replacement therapy and comprehensive conservative care 1

Critical Pitfalls to Avoid

• Never discontinue RAS inhibitors for creatinine increases <30% without first checking for volume depletion 1
• Avoid protein restriction in children and in older adults with frailty/sarcopenia, as this causes growth impairment and muscle wasting 1, 3, 4
• Do not prescribe very low-protein diets to metabolically unstable patients 1, 4
• Avoid aggressive BP lowering in frail older adults with high fall risk 1, 3
• Do not use NSAIDs in CKD patients due to nephrotoxicity and worsening hypertension 7, 6
• Adjust drug dosing for reduced eGFR, particularly antibiotics and oral hypoglycemic agents 6
• Avoid iodinated contrast media in advanced CKD 2
• Never assume normal renal function based on serum creatinine alone in elderly patients—always calculate eGFR 4, 7