Chronic Kidney Disease Management
Introduction to CKD Management
- The American College of Cardiology recommends implementing a comprehensive treatment strategy targeting blood pressure control, cardiovascular risk reduction, lifestyle modifications, and monitoring for metabolic complications to reduce CKD progression and improve mortality and quality of life outcomes 1
Risk Stratification and Monitoring
- Use validated risk prediction equations incorporating eGFR and albuminuria to guide management intensity, with a 2-year kidney failure risk >10% triggering multidisciplinary care and >40% initiating kidney replacement therapy preparation 2
- For cardiovascular risk assessment, apply externally validated models developed specifically for CKD populations that incorporate both eGFR and albuminuria 3
Blood Pressure Management
- Target blood pressure <130/80 mmHg in patients with albuminuria ≥30 mg/24 hours and <140/90 mmHg in those without albuminuria 4
- Initiate angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARBs) as first-line therapy, particularly in patients with albuminuria >300 mg/24 hours 4
Cardiovascular Risk Reduction
- Prescribe statin therapy for all adults ≥50 years with CKD regardless of GFR category 5
- For adults 18-49 years with CKD, initiate statins if they have coronary disease, diabetes, prior stroke, or 10-year coronary event risk >10% 4
Lifestyle Modifications
- Advise patients to perform moderate-intensity physical activity for at least 150 minutes per week, adjusted to cardiovascular and physical tolerance 1, 3
- Encourage weight loss in patients with obesity and CKD through diet, physical activity, and behavioral therapy 6
Dietary Management
- Advise adoption of healthy, diverse diets with higher consumption of plant-based foods compared to animal-based foods and lower consumption of ultraprocessed foods 1, 3
- Maintain protein intake at 0.8 g/kg body weight/day in adults with CKD G3-G5 1, 6
- Limit sodium intake to <2 g per day (equivalent to <90 mmol/day or <5 g sodium chloride/day) 1
Glycemic Control in Diabetic CKD
- Target hemoglobin A1c of approximately 7% 4
- Use metformin as first-line therapy when eGFR ≥30 ml/min/1.73m² 4
Management of Metabolic Complications
- Provide pharmacological treatment with or without dietary intervention when serum bicarbonate <18 mmol/L 5
- Treat symptomatic hyperuricemia (gout) with urate-lowering therapy, preferring xanthine oxidase inhibitors over uricosuric agents 5
Medication Management
- Adjust all medication dosages according to kidney function 5
- Prefer non-vitamin K antagonist oral anticoagulants (NOACs) over vitamin K antagonists, with appropriate dose adjustments based on GFR 5
Multidisciplinary Care and Referrals
- Refer to nephrology when 5-year kidney failure risk is 3-5% or when eGFR <30 ml/min/1.73m² or albuminuria ≥300 mg per 24 hours 7
- Refer to renal dietitians for specialized nutritional counseling 1, 4