Managing Chronic Kidney Disease

Core Pharmacologic Therapy

The KDIGO guidelines recommend a comprehensive treatment strategy centered on SGLT2 inhibitors as first-line therapy for most CKD patients, combined with RAS inhibition (ACE inhibitor or ARB) at maximum tolerated dose when hypertension or albuminuria is present, targeting systolic blood pressure <120 mmHg, alongside statin-based lipid therapy 1, 2
SGLT2 inhibitors should be initiated in most CKD patients and continued until dialysis or transplant, representing the most significant advancement in CKD management, with robust evidence for delaying progression and reducing cardiovascular complications 2, 3
RAS inhibition (ACE inhibitor or ARB) must be prescribed at maximum tolerated dose when albuminuria is present, and is first-line when hypertension exists, with titration to the highest approved dose that is tolerated to maximize kidney protection 2, 4
Statin therapy (moderate to high-intensity) or statin/ezetimibe combination is mandatory for all adults ≥50 years with eGFR <60 mL/min/1.73 m² (CKD G3a-G5), choosing regimens that maximize absolute LDL cholesterol reduction 2, 3, 4, 5

Target systolic blood pressure <120 mmHg for most CKD patients, representing a more aggressive target than previous guidelines and supported by cardiovascular outcome data 2, 3
For patients without albuminuria, target blood pressure <140/90 mmHg 4, 5
For patients with albuminuria ≥30 mg/24h, target blood pressure <130/80 mmHg 4, 5
When albuminuria is present, ACE inhibitor or ARB must be first-line antihypertensive therapy, given the proven kidney protective effects 2, 4

Advise patients to undertake moderate-intensity physical activity for at least 150 minutes per week, adjusted to their cardiovascular and physical tolerance 1, 2, 4, 5
Patients should be advised to avoid sedentary behavior 1, 4, 5
For people at higher risk of falls, provide specific advice on the intensity of physical activity and the type of exercises 1
Encourage weight loss for patients with obesity and CKD 1, 4, 5

Advise patients to adopt healthy, diverse diets with higher consumption of plant-based foods compared to animal-based foods and lower consumption of ultra-processed foods 1, 2, 4, 5
Consider a plant-based "Mediterranean-style" diet in addition to lipid-modifying therapy to reduce cardiovascular risk 3
Maintain protein intake at 0.8 g/kg body weight/day in adults with CKD G3-G5 1, 2, 4, 5
Avoid high protein intake (>1.3 g/kg body weight/day) in adults with CKD at risk of progression 1, 2, 4, 5

Prescribe oral low-dose aspirin for secondary prevention in people with CKD and established ischemic cardiovascular disease 2, 3, 5
Consider other antiplatelet therapy (e.g., P2Y12 inhibitors) when there is aspirin intolerance 3
Use non-vitamin K antagonist oral anticoagulants (NOACs) in preference to vitamin K antagonists (e.g., warfarin) for thromboprophylaxis in atrial fibrillation in people with CKD G1-G4 2, 3, 5

Use validated risk prediction tools to guide management decisions, with the Kidney Failure Risk Equation supporting identification of patients at high risk of progressive kidney disease 4, 5
Estimate 10-year cardiovascular risk using a validated risk tool 2, 3
Test people at risk for CKD using both urine albumin measurement and assessment of glomerular filtration rate (GFR) 4, 5

Consider GFR when dosing medications cleared by the kidneys 4, 5
For most clinical settings, validated eGFR equations using serum creatinine are appropriate for drug dosing 4, 5
Perform thorough medication review periodically and at transitions of care to assess adherence, continued indication, and potential drug interactions 4, 5

Refer adults with CKD to specialist kidney care services when they have ACR ≥30 mg/g (3 mg/mmol) or PCR ≥200 mg/g (20 mg/mmol) 4, 5
Refer adults with CKD to specialist kidney care services when they have persistent hematuria 4, 5
Refer adults with CKD to specialist kidney care services when they have any sustained decrease in eGFR 4, 5

Encourage children with CKD to undertake physical activity aiming for WHO-advised levels (≥60 minutes daily) and to achieve a healthy weight 1, 4, 5
Do not restrict protein intake in children with CKD due to the risk of growth impairment, with target protein and energy intake at the upper end of the normal range for healthy children to promote optimal growth 1, 4, 5
In older adults with underlying conditions such as frailty and sarcopenia, consider higher protein and calorie dietary targets 1

Never prescribe NSAIDs in CKD due to nephrotoxicity risk and potential for acute kidney injury—use low-dose colchicine or glucocorticoids instead for inflammatory conditions like acute gout 2
Do NOT use agents to lower serum uric acid in CKD patients with asymptomatic hyperuricemia to delay CKD progression 2
Do not discontinue RAS inhibitors due to modest increases in serum creatinine or potassium unless there are specific contraindications 3