What is the recommended management and treatment plan for chronic kidney disease (CKD), including blood pressure control, proteinuria reduction, metabolic complication management, and preparation for renal replacement therapy?

Management of Chronic Kidney Disease

Implement SGLT2 inhibitors as first-line therapy for most CKD patients, combined with blood pressure control targeting systolic <120 mmHg, RAS inhibition at maximum tolerated doses for those with albuminuria, and statin therapy—this comprehensive approach reduces mortality, cardiovascular events, and kidney failure progression. 1

Core Pharmacologic Pillars

First-Line Therapy: SGLT2 Inhibitors

• Start SGLT2 inhibitors in all eligible CKD patients regardless of diabetes status to reduce CKD progression and cardiovascular events 1
• Continue until dialysis or transplantation 1
• These agents provide cardioprotective and renoprotective benefits independent of glucose-lowering effects 2
• Temporarily discontinue 48-72 hours before elective surgery, but ensure restart post-operatively to prevent unintentional harm 2

Blood Pressure Management

• Target systolic blood pressure <120 mmHg using standardized office measurement in adults with CKD when tolerated 1
• Use less intensive targets in patients with frailty, high fall risk, limited life expectancy, or symptomatic postural hypotension 1
• In children with CKD, target 24-hour mean arterial pressure ≤50th percentile for age, sex, and height by ambulatory blood pressure monitoring 1

RAS Inhibition for Proteinuria Reduction

• Start ACE inhibitors or ARBs for patients with severely increased albuminuria (≥300 mg/24h) regardless of diabetes status 1
• Start ACE inhibitors or ARBs for diabetic patients with moderately-to-severely increased albuminuria (≥30 mg/24h) 1
• Titrate to the highest approved tolerated dose because proven benefits were achieved using these doses in clinical trials 1
• Do not discontinue for minor creatinine increases (≤30%) in the absence of volume depletion 2
• Monitor serum creatinine and potassium 2-4 weeks after initiation or dose adjustment 1, 3
• Never combine ACE inhibitors, ARBs, and direct renin inhibitors 1

Nonsteroidal Mineralocorticoid Receptor Antagonists

• Use nonsteroidal MRAs (finerenone) in diabetic patients at increased cardiovascular or CKD progression risk, or those unable to use SGLT2 inhibitors 1
• Consider steroidal MRAs for resistant hypertension 1

Cardiovascular Risk Reduction with Statins

• Prescribe statin or statin/ezetimibe combination for all adults ≥50 years with eGFR <60 mL/min/1.73 m² 1
• Prescribe statins for adults ≥50 years with eGFR ≥60 mL/min/1.73 m² 1
• For adults 18-49 years, prescribe statins if they have coronary disease, diabetes, prior ischemic stroke, or 10-year cardiovascular risk >10% 1
• Consider PCSK9 inhibitors for patients with indications for their use 1
• Continue statin therapy until dialysis or transplantation 1

Lifestyle Modifications

Dietary Management

• Restrict sodium intake to <2 g/day (equivalent to <90 mmol/day or <5 g sodium chloride/day) 1
• Exception: avoid sodium restriction in patients with sodium-wasting nephropathy 1
• Maintain protein intake of 0.8 g/kg body weight/day in adults with CKD G3-G5 1
• Avoid high protein intake >1.3 g/kg body weight/day in adults at risk of progression 1
• In willing and able patients at 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
• Never restrict protein in children with CKD due to growth impairment risk—target upper end of normal range 1
• In older adults with frailty and sarcopenia, consider higher protein and calorie targets 1
• Consider plant-based "Mediterranean-style" diet to reduce cardiovascular risk 1

Physical Activity

• Advise moderate-intensity physical activity for cumulative duration of at least 150 minutes per week or to a level compatible with cardiovascular and physical tolerance 1
• Advise avoiding sedentary behavior 1
• For patients at higher fall risk, provide specific advice on intensity (low, moderate, or vigorous) and type of exercises (aerobic vs. resistance) 1
• Encourage children with CKD to achieve ≥60 minutes daily physical activity per WHO guidelines 1

Weight and Tobacco Management

• Advise patients with obesity and CKD to lose weight 1
• Strongly encourage cessation of all tobacco products 1

Management of Metabolic Complications

Anemia Management

• Manage anemia where indicated as part of comprehensive CKD care 1
• Use erythropoietin for correction of anemia in moderate-severe CKD 4

Mineral and Bone Disorder (CKD-MBD)

• Manage CKD-MBD where indicated 1
• Administer vitamin D derivatives for correction of mineral metabolism disorders 4

Metabolic Acidosis

• Manage acidosis where indicated 1
• Provide oral bicarbonate supplementation to maintain bicarbonate within normal range for patients with serum bicarbonate <22 mmol/L unless contraindicated 3

Potassium Abnormalities

• Manage potassium abnormalities where indicated 1
• Use potassium-wasting diuretics and/or potassium-binding agents to reduce serum potassium to normal, enabling use of RAS blocking medications 1

Hyperglycemia Management

• Manage hyperglycemia as per KDIGO Diabetes Guideline, including use of GLP-1 receptor agonists where indicated 1
• Target HbA1c ~7.0% to prevent microvascular complications 3

Additional Cardiovascular Therapies

Antiplatelet Therapy

• Prescribe oral low-dose aspirin for secondary prevention in patients with established ischemic cardiovascular disease 1
• Consider other antiplatelet therapy (e.g., P2Y12 inhibitors) when aspirin intolerance exists 1

Atrial Fibrillation Management

• Use opportunistic pulse-based screening when measuring blood pressure, followed by wearable device or Holter ECG testing 1
• Provide prophylaxis against stroke and systemic thromboembolism based on CHADS-VASc risk factors 1
• Use medical therapy (e.g., beta blockade) to control ventricular rate to <90 bpm at rest 1
• For persistent symptoms despite adequate rate control, consider rhythm control with cardioversion, antiarrhythmic therapy, and/or catheter ablation 1

Monitoring and Risk Assessment

Regular Reassessment

• Reassess risk factors every 3-6 months 1
• Monitor blood pressure at every clinical encounter using standardized technique 2
• Monitor serum creatinine, eGFR, electrolytes, and urine albumin-to-creatinine ratio 3 times per year for CKD G3b (eGFR 30-44) 3

Risk Prediction for Nephrology Referral

• Use externally validated risk equations to estimate absolute risk of kidney failure in CKD G3-G5 1
• Use 5-year kidney failure risk of 3-5% to determine need for nephrology referral 1
• Use 2-year kidney failure risk >10% to determine timing of multidisciplinary care 1
• Use 2-year kidney failure risk >40% to determine timing of preparation for kidney replacement therapy including vascular access planning or transplantation referral 1
• Use disease-specific validated prediction equations for IgA nephropathy and autosomal dominant polycystic kidney disease 1

Preparation for Renal Replacement Therapy

Timing of Referral

• Refer for planning renal replacement therapy when progressive CKD has 10-20% or higher risk of kidney failure within 1 year using validated risk prediction tools 1
• Include discussion of conservative management without renal replacement therapy in the planning process 1

Multidisciplinary Care

• Manage patients with progressive CKD in multidisciplinary care setting when eGFR <30 mL/min/1.73 m², rapid progression occurs, or complex comorbidity exists 1
• Ensure access to dietary counseling, education about different renal replacement therapy modalities, transplant options, vascular access surgery, and ethical, psychological, and social care 1

Initiation of Dialysis

• Initiate dialysis when symptoms or signs attributable to kidney failure are present (serositis, acid-base or electrolyte abnormalities) 1

Critical Medication Considerations and Pitfalls

Nephrotoxin Avoidance

• Never prescribe NSAIDs in CKD stage 3B or higher—they significantly increase acute kidney injury and CKD progression risk 3
• Avoid gadolinium-containing contrast in patients with eGFR <15 mL/min/1.73 m² unless no alternative exists 3
• Avoid iodinated contrast when possible in patients with eGFR <30 mL/min/1.73 m² 2
• Avoid acetaminophen, bisphosphonates, oral estrogens, and herbals 4

Medication Dosing

• Adjust all medication dosages according to kidney function using eGFR calculations 2
• Monitor therapeutic medication levels for drugs with narrow therapeutic windows 2

Common Errors to Avoid

• Never discontinue all four pharmacologic pillars simultaneously during acute illness without a clear restart plan 2
• Do not avoid ACE inhibitors/ARBs due to fear of hyperkalemia or modest creatinine elevation—benefits far outweigh risks when properly monitored 2
• Do not delay SGLT2 inhibitor initiation in eligible patients—early intervention provides maximum benefit 2