Management of Chronic Kidney Disease

Comprehensive Treatment Approach

The American College of Cardiology and other guideline societies recommend ACE inhibitors or ARBs as first-line therapy for hypertension in patients with albuminuria, administered at maximum tolerated doses 1, 2
Target blood pressure should be <120 mm Hg systolic for most patients with CKD, according to the American Heart Association 2, 4
Dihydropyridine calcium channel blockers and/or diuretics can be added if needed to achieve BP targets, as suggested by the American Journal of Kidney Diseases 1, 5
For Black patients with CKD, initial therapy should include a thiazide-type diuretic or calcium channel blocker, either alone or in combination with a RAS blocker, as recommended by the Mayo Clinic Proceedings 6

ACE inhibitors or ARBs are strongly recommended (Class 1B) for patients with severely increased albuminuria (A3) without diabetes, according to the Annals of Internal Medicine 2
ACE inhibitors or ARBs are suggested (Class 2C) for patients with moderately increased albuminuria (A2) without diabetes, as suggested by the Annals of Internal Medicine 2

Monitor serum creatinine and potassium within 2-4 weeks after initiation or dose increase of ACE inhibitors or ARBs, as recommended by the Annals of Internal Medicine 2
Continue therapy unless serum creatinine rises by more than 30% within 4 weeks of initiation or dose increase, according to the Annals of Internal Medicine 2

For patients with diabetic CKD, SGLT2 inhibitors are recommended for those with eGFR ≥20 mL/min/1.73 m² and type 2 diabetes, as suggested by the American Diabetes Association and Kidney International 8, 1, 9
GLP-1 receptor agonists are suggested for cardiovascular risk reduction in patients with diabetic CKD, according to Diabetes Care and Kidney International 8, 9

Advise patients to adopt healthy and diverse diets with higher consumption of plant-based foods compared to animal-based foods, as recommended by Kidney International and the American Journal of Kidney Diseases 1, 5
Suggest maintaining a protein intake of 0.8 g/kg body weight/day in adults with CKD G3-G5, according to the American Journal of Kidney Diseases 5
Avoid high protein intake (>1.3 g/kg/day) in adults with CKD at risk of progression, as recommended by the American Journal of Kidney Diseases 5
Encourage moderate-intensity physical activity for at least 150 minutes per week, or to a level compatible with cardiovascular and physical tolerance, as suggested by Kidney International and the American Journal of Kidney Diseases 1, 5

Regular risk factor reassessment every 3-6 months, as recommended by Kidney International and the American Journal of Kidney Diseases 1, 5
Monitor for complications of CKD such as hyperkalemia, metabolic acidosis, hyperphosphatemia, vitamin D deficiency, secondary hyperparathyroidism, and anemia, according to Kidney International 9