Chronic Kidney Disease Management

Diagnosis and Monitoring

An eGFR value of 50 mL/min/1.73 m² corresponds to CKD stage G3a (45-59 mL/min/1.73 m²) 1
Initial assessment of impaired renal function should include measurement of both estimated glomerular filtration rate (eGFR) and albuminuria (UACR) for proper diagnosis, staging, and risk stratification of kidney dysfunction, as recommended by the National Kidney Foundation 2
Cystatin C measurement can be considered for more accurate GFR estimation, especially in patients with borderline eGFR values 2
Confirming CKD diagnosis by repeating eGFR measurement and assessing albuminuria (UACR) is recommended by the Kidney International guideline 3
Establishing chronicity (>3 months duration) is essential and can be done through review of past eGFR measurements, assessment of albuminuria/proteinuria, and evaluation of medical history for CKD risk factors 3
Complete CKD classification should be based on cause (underlying etiology), GFR category (e.g. G3a: 45-59 mL/min/1.73m²), and albuminuria category (A1, A2, or A3) 3
Monitor eGFR and albuminuria at least annually, as recommended by the American Diabetes Association 1, 4, 5, 6
Frequency of monitoring should increase with declining eGFR and increasing albuminuria, with serum creatinine, BUN, and eGFR checked every 1-3 months for eGFR <60 mL/min/1.73 m² 7, 1, 5, 6

For eGFR <60 mL/min/1.73 m², laboratory evaluations should be performed every 6-12 months, including serum electrolytes, hemoglobin, calcium, phosphate, PTH, vitamin D levels, and lipid panel 8
Serum potassium monitoring should be performed for patients on ACE inhibitors, ARBs, or diuretics, as recommended by the Diabetes Care and the Kidney International 9, 1
Hemoglobin should be checked at least every 3 months, and if hemoglobin <12 g/dL (women) or <13 g/dL (men), a complete anemia workup should be performed, including iron studies, with consideration of erythropoietin or analogue if anemia persists despite iron therapy, as suggested by the American Diabetes Association and the Kidney International 10

Target blood pressure <130/80 mmHg, as recommended by the American Heart Association 11, 1
Target blood pressure is <130/80 mmHg for patients with UACR <30 mg/g, and <130/80 mmHg for patients with UACR ≥30 mg/g, as recommended by the American College of Physicians 7
Target blood pressure is <130/80 mmHg for patients with proteinuria <1 g/day, and <125/75 mmHg for patients with proteinuria >1 g/day, to reduce the risk of disease progression and mortality, as recommended by the American Diabetes Association and the Kidney International 12, 13, 14
Sodium intake should be restricted to <2 g/day to improve BP control and enhance medication efficacy, as recommended by the Kidney International and the American Diabetes Association 15, 16, 17, 18

First-line agents for CKD management include ACE inhibitors or ARBs, especially if albuminuria is present (>30 mg/g), as recommended by the American Diabetes Association 1, 4
Small increases in serum creatinine (up to 30%) are expected and do not warrant discontinuation of ACE inhibitors or ARBs 4
ACE inhibitors or ARBs should be used as first-line agents for patients with albuminuria (>300 mg/g), with monitoring of serum creatinine and potassium within 7-14 days after initiation, as recommended by the American Diabetes Association and the Kidney International 19, 18, 20
Statin therapy is recommended for adults ≥50 years with eGFR <60 mL/min/1.73 m², as recommended by the Kidney International society 3
SGLT2 inhibitors are indicated to reduce CKD progression and cardiovascular events in patients with eGFR ≥20 mL/min/1.73m², regardless of albuminuria status, as suggested by the American Diabetes Association and the Kidney International 1, 21, 2
GLP-1 receptor agonists can be considered for diabetic patients with eGFR as low as 15 mL/min/1.73m², according to the European Society of Cardiology and the Kidney International 21, 20

Consider Mediterranean-style or DASH diet, as recommended by the Kidney International society 3
Weight management, smoking cessation, and regular physical activity are encouraged, with consideration of a Mediterranean or DASH eating pattern, as suggested by the American Diabetes Association and the Kidney International 22, 9, 17, 23, 24, 25
Protein intake should be approximately 0.8 g/kg/day for patients with kidney disease, as recommended by the National Kidney Foundation and the American Diabetes Association 19, 1, 16, 17, 18, 15

Consider referral to nephrology for rapid progression (decline in eGFR >5 mL/min/1.73 m² per year), significant albuminuria (UACR >300 mg/g), or difficult-to-manage complications, as recommended by the Mayo Clinic Proceedings 11
Referral for kidney transplant evaluation should be considered if eligible, with preservation of veins suitable for potential future vascular access, as suggested by the American Journal of Kidney Diseases and the Kidney International 18, 10, 26
Consider renal replacement therapy options when eGFR <30 mL/min/1.73m², including hemodialysis, peritoneal dialysis, and transplantation, as recommended by the American Journal of Kidney Diseases and the Kidney International 27, 18, 10, 26

Patient education on "sick day rules" is essential, including temporarily stopping ACE inhibitors/ARBs and diuretics during acute illness with volume depletion, as recommended by the American Diabetes Association and the Kidney International 15, 28
All CKD patients are at increased risk for acute kidney injury (AKI) and should avoid nephrotoxic medications during acute illness, as recommended by the American Diabetes Association 7, 29
Common complications of CKD, such as hypertension, volume overload, electrolyte abnormalities, metabolic acidosis, anemia, and metabolic bone disease, should be monitored and evaluated, as recommended by the Diabetes Care and the Kidney International 30, 9
Reversible causes of AKI, such as volume depletion, obstruction, and medications, should be identified and treated, as recommended by the Diabetes Care and the Kidney International 1