CKD Management Guidelines

Pharmacological Management

• The KDIGO guidelines strongly recommend a multi-drug approach for CKD management, prioritizing SGLT2 inhibitors, RAS inhibitors, and nonsteroidal MRAs based on albuminuria status and eGFR to reduce mortality and improve quality of life 1, 2
• RASi (ACEi or ARB) are recommended for CKD with severely increased albuminuria (G1-G4, A3) without diabetes (strong recommendation) 1, 3
• RASi (ACEi or ARB) are recommended for CKD with moderately increased albuminuria (G1-G4, A2) without diabetes (conditional recommendation) 1, 3
• RASi (ACEi or ARB) are recommended for CKD with moderately-to-severely increased albuminuria (G1-G4, A2 and A3) with diabetes (strong recommendation) 1, 3
• Use the highest approved dose of RASi that is tolerated to achieve maximum benefits 1, 4
• Continue ACEi/ARB even when eGFR falls below 30 ml/min per 1.73 m² 1, 5
• Avoid any combination of ACEi, ARB, and direct renin inhibitor therapy 1, 3
• Monitor serum creatinine and potassium within 2-4 weeks of initiation or dose increase of RASi 1, 6
• Continue RASi therapy unless serum creatinine rises by more than 30% within 4 weeks 1, 6
• SGLT2 inhibitors are strongly recommended for type 2 diabetes with CKD and eGFR ≥20 ml/min per 1.73 m² 1, 7
• SGLT2 inhibitors are strongly recommended for CKD with eGFR ≥20 ml/min per 1.73 m² and urine ACR ≥200 mg/g 1, 7
• SGLT2 inhibitors are strongly recommended for CKD with heart failure, regardless of albuminuria level 1, 7
• Nonsteroidal MRAs are suggested for adults with T2D, eGFR >25 ml/min per 1.73 m², normal potassium, and albuminuria >30 mg/g despite maximum tolerated RASi 1, 7
• GLP-1 receptor agonists are recommended for adults with T2D and CKD who haven't achieved glycemic targets despite metformin and SGLT2i, or who cannot use these medications 1, 7

Blood Pressure Management

• Target systolic BP <120 mmHg in adults with high BP and CKD, when tolerated 3, 8
• Consider less intensive BP-lowering therapy in patients with frailty, high fall risk, limited life expectancy, or symptomatic postural hypotension 3, 8
• For children with CKD, target 24-hour mean arterial pressure by ABPM to ≤50th percentile for age, sex, and height 3, 8
• Monitor BP in children once yearly with ABPM and every 3-6 months with standardized office BP 3, 8

Dietary and Lifestyle Recommendations

• Maintain protein intake of 0.8 g/kg body weight/day in adults with CKD G3-G5 3, 8
• Avoid high protein intake (>1.3 g/kg/day) in adults with CKD at risk of progression 3, 8
• Limit sodium intake to <2 g/day (<5 g sodium chloride/day) in people with CKD 3, 5
• Recommend moderate-intensity physical activity for at least 150 minutes per week 8, 6
• Avoid sedentary behavior 8, 6

Metabolic Management

• For adults ≥50 years with eGFR <60 ml/min per 1.73 m², recommend statin or statin/ezetimibe combination 9
• For adults ≥50 years with CKD and eGFR ≥60 ml/min per 1.73 m², recommend statin treatment 9
• Treat symptomatic hyperuricemia in CKD patients 9
• Prefer xanthine oxidase inhibitors over uricosuric agents 9
• Consider pharmacological treatment with/without dietary intervention to prevent acidosis (serum bicarbonate <18 mmol/l) 7

Common Pitfalls and Caveats

• Continue RASi when eGFR falls below 30 ml/min per 1.73 m² unless specific adverse effects occur 1, 5
• The reversible decrease in eGFR upon SGLT2i initiation is not an indication to discontinue therapy 1, 7
• Hyperkalemia with RASi should be managed with measures to reduce potassium rather than immediately stopping the medication 1, 6
• Low or very low-protein diets should not be prescribed in metabolically unstable CKD patients 3, 8

Tirzepatide in Chronic Kidney Disease Management

Introduction to CKD Management

• The Kidney Disease: Improving Global Outcomes (KDIGO) 2024 guidelines prioritize long-acting GLP-1 receptor agonists for patients with type 2 diabetes and CKD who haven't achieved glycemic targets despite metformin and SGLT2 inhibitor use, with a recommendation to choose GLP-1 RAs with documented cardiovascular benefits 10

Treatment Hierarchy for CKD

• For patients with type 2 diabetes and CKD, the evidence-based treatment sequence is: first-line SGLT2 inhibitors for eGFR ≥20 mL/min/1.73 m² (strong recommendation) 11, 12
• The treatment sequence continues with second-line RAS inhibitors (ACEi or ARB) at maximum tolerated doses for albuminuria 11, 12
• Third-line treatment includes nonsteroidal MRAs for eGFR >25 mL/min/1.73 m² with persistent albuminuria >30 mg/g despite RASi 12
• For glycemic control, long-acting GLP-1 RAs with proven cardiovascular benefits are recommended if targets are not met 10, 13

Special Considerations

• In patients with eGFR <45 mL/min/1.73 m², SGLT2 inhibitors lose glucose-lowering efficacy, though kidney and cardiovascular benefits persist, and metformin should be dose-reduced at eGFR <45 and stopped at eGFR <30 mL/min/1.73 m² 13
• The American Diabetes Association recommends against combining tirzepatide with DPP-4 inhibitors, as there is no added glucose-lowering benefit beyond tirzepatide alone 13
• The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines advise against withholding tirzepatide based solely on reduced eGFR, as no dose adjustment is needed even in ESRD, and against discontinuing SGLT2 inhibitors when adding tirzepatide, as the combination provides complementary benefits for CKD progression and cardiovascular outcomes 10, 12