Management of Chronic Kidney Disease

Risk Assessment and Monitoring

The Kidney International guidelines recommend using validated risk prediction tools to guide management decisions, with a 2-year kidney failure risk threshold of >10% determining timing for multidisciplinary care and >40% for kidney replacement therapy preparation 1
Establish the cause of CKD using clinical context, personal and family history, social and environmental factors, medications, physical examination, laboratory measures, imaging, and genetic and pathologic diagnosis 2
Test people at risk for CKD using both urine albumin measurement and assessment of glomerular filtration rate (GFR) 2
Repeat tests to confirm presence of CKD following incidental detection of elevated urinary albumin-to-creatinine ratio (ACR), hematuria, or low estimated GFR (eGFR) 2

The American College of Cardiology recommends targeting blood pressure <140/90 mmHg in CKD patients without albuminuria 1
Aim for a lower target of <130/80 mmHg in patients with albuminuria ≥30 mg/24h 1
Use angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARBs) as first-line therapy, especially in patients with albuminuria 1
Titrate ACEi or ARBs to the highest approved dose that is tolerated to maximize kidney protection 1

The Kidney International guidelines recommend prescribing statins or statin/ezetimibe combination for adults ≥50 years with eGFR <60 ml/min/1.73 m² (CKD G3a-G5) 1, 3
Choose statin regimens that maximize absolute reduction in LDL cholesterol to achieve largest treatment benefits 3
For adults aged 18-49 years with CKD, consider statin therapy for those with coronary disease, diabetes mellitus, prior ischemic stroke, or estimated 10-year incidence of coronary death or nonfatal MI >10% 3

The Kidney International guidelines recommend moderate-intensity physical activity for at least 150 minutes per week, adjusted to cardiovascular and physical tolerance 4, 5, 1
Advise patients to avoid sedentary behavior 4, 5
Encourage weight loss for patients with obesity and CKD 4, 5
Promote smoking cessation 4, 1

The Kidney International guidelines recommend advising adoption of healthy, diverse diets with higher consumption of plant-based foods and lower consumption of ultra-processed foods 4, 5, 1
Maintain protein intake at 0.8 g/kg body weight/day in adults with CKD G3-G5 4, 5, 1
Avoid high protein intake (>1.3 g/kg body weight/day) in adults with CKD at risk of progression 4, 5, 1

Consider GFR when dosing medications cleared by the kidneys 6, 7
For most people and clinical settings, validated eGFR equations using serum creatinine are appropriate for drug dosing 6, 7
Perform thorough medication review periodically and at transitions of care to assess adherence, continued indication, and potential drug interactions 6, 7

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) 6
Refer adults with CKD to specialist kidney care services when they have persistent hematuria 6
Refer adults with CKD to specialist kidney care services when they have any sustained decrease in eGFR 6

For children with CKD, encourage physical activity aiming for WHO-advised levels (≥60 minutes daily) and achievement of healthy weight 4, 5, 1
Do not restrict protein intake in children with CKD due to risk of growth impairment 4, 5, 1
When prescribing medications to people with CKD who are of child-bearing potential, always review teratogenicity potential and provide regular reproductive and contraceptive counseling 7