What are the treatment options for Chronic Kidney Disease (CKD)?

From the Guidelines

Treating chronic kidney disease (CKD) requires a comprehensive approach focusing on slowing disease progression and managing complications, with the most recent guidelines from 2024 and 2025 emphasizing the importance of blood pressure control, lipid management, and individualized treatment plans. The 2024 ESC guidelines for the management of elevated blood pressure and hypertension recommend lowering systolic BP to a range of 130–139 mmHg in patients with diabetic or non-diabetic CKD, with individualized treatment considered according to its tolerability and impact on renal function and electrolytes 1.

Key Components of CKD Management

• Controlling underlying conditions like diabetes and hypertension, with medications such as ACE inhibitors (like enalapril 5-40 mg daily or lisinopril 10-40 mg daily) or ARBs (such as losartan 25-100 mg daily) recommended as they protect kidney function while controlling blood pressure
• Dietary modifications, including limiting sodium to 2,000 mg daily, restricting protein to 0.8 g/kg body weight daily, and controlling potassium and phosphorus intake based on blood levels
• Managing anemia with erythropoiesis-stimulating agents like epoetin alfa when hemoglobin falls below 10 g/dL
• Addressing mineral and bone disorders with phosphate binders (calcium acetate, sevelamer) and vitamin D supplements (calcitriol 0.25-1 mcg daily) as needed
• Regular monitoring of kidney function, electrolytes, and metabolic parameters, with frequency increasing as CKD advances

Lipid Management and Blood Pressure Control

• The KDOQI US commentary on the KDIGO 2024 clinical practice guideline for the evaluation and management of CKD recommends choosing statin-based regimens to maximize the absolute reduction in low-density lipoprotein (LDL) cholesterol to achieve the largest treatment benefits 1
• The 2024 ESC guidelines recommend targeting systolic BP to 120–129 mmHg in adults with moderate-to-severe CKD who are receiving BP-lowering drugs and who have eGFR >30 mL/min/1.73 m², if tolerated 1

Individualized Treatment Plans

• Individualized treatment should be considered according to its tolerability and impact on renal function and electrolytes, with RAS blockers recommended as part of the treatment strategy in hypertensive patients in the presence of microalbuminuria or proteinuria 1
• Preparation for renal replacement therapy through dialysis or transplantation should begin early for advanced CKD (stages 4-5) 1

From the FDA Drug Label

In controlled trials, patients experienced greater risks for death, serious adverse cardiovascular reactions, and stroke when administered ESAs to target a hemoglobin level of greater than 11 g/dL. No trial has identified a hemoglobin target level, ESA dose, or dosing strategy that does not increase these risks Individualize dosing and use the lowest dose of PROCRIT sufficient to reduce the need for RBC transfusions [see Warnings and Precautions (5. 1)] . For adult patients with CKD on dialysis: Initiate PROCRIT treatment when the hemoglobin level is less than 10 g/dL. If the hemoglobin level approaches or exceeds 11 g/dL, reduce or interrupt the dose of PROCRIT.

Treating CKD with Epoetin Alfa (IV):

• The recommended starting dose for adult patients with CKD is 50 to 100 Units/kg 3 times weekly intravenously or subcutaneously.
• The goal is to use the lowest dose of PROCRIT sufficient to reduce the need for RBC transfusions.
• Hemoglobin levels should be monitored at least weekly until stable, then at least monthly.
• Dose adjustments should be made cautiously, with dose increases not more frequent than once every 4 weeks.
• If the hemoglobin level exceeds 11 g/dL, the dose of PROCRIT should be reduced or interrupted 2 2.

From the Research

Treatment Options for CKD

• Lifestyle modifications, such as walking, weight loss, and adherence to a low-protein diet or the alternate Mediterranean diet, can slow the progression of CKD 3.
• Controlling hypertension and diabetes mellitus is also crucial in delaying the progression of CKD 3, 4.
• Medical therapies, including RAAS blockade, SGLT2 inhibitors, pentoxifylline, and finerenone, are approved for managing CKD 3.
• Angiotensin receptor blockers (ARBs) have been shown to be effective in improving renal dysfunction and reducing proteinuria 4.

Dietary Interventions

• Dietary changes, such as increasing fruit and vegetable intake, following a Mediterranean diet, or adopting a carbohydrate-restricted low-iron, polyphenol-enriched diet, may have beneficial effects on CKD progression 5, 6.
• Dietary interventions have been associated with improved health-related quality of life, higher estimated glomerular filtration rate (eGFR), and lower blood pressure and serum cholesterol levels 6.
• However, the evidence for the effectiveness of dietary interventions in CKD is generally of low quality, and large-scale pragmatic RCTs are needed to confirm these findings 6.

Promoting Adherence to Nutritional Advice

• Individualized dietary advice and education efforts adapted to each patient's changing lifestyle and CKD variables may improve adherence to nutritional advice 7.
• Practical strategies for increasing dietary adherence include communicating with "talking control" principles, integrating patient-owned technology, and focusing on a single goal rather than multiple goals 7.
• Involving the total patient food environment and creating active learning and coping strategies may also promote adherence to nutritional advice 7.