CKD Management Guidelines

Introduction to CKD Management

• The American College of Cardiology and other guideline societies recommend modern CKD management to rest on four evidence-based pillars: SGLT2 inhibitor therapy, RAAS inhibition with ACE inhibitors or ARBs, blood pressure control targeting <120 mmHg systolic, and statin-based cardiovascular risk reduction 1

SGLT2 Inhibitor Therapy

• The Kidney International guideline suggests that SGLT2 inhibitors are strongly recommended (Grade 1A) for patients with type 2 diabetes, CKD, and eGFR ≥20 mL/min/1.73 m² 2
• The Kidney International guideline also recommends SGLT2 inhibitors for adults with eGFR ≥20 mL/min/1.73 m² with urine ACR ≥200 mg/g (≥20 mg/mmol), regardless of diabetes status (Grade 1A) 2
• SGLT2 inhibitors are suggested for adults with eGFR 20-45 mL/min/1.73 m² with urine ACR <200 mg/g (Grade 2B) 2

RAAS Inhibition

• The Annals of Internal Medicine guideline recommends ACE inhibitors or ARBs at maximum tolerated dose for severely increased albuminuria (A3, >300 mg/24 hours) in both diabetic and non-diabetic patients (Grade 1B) 3, 2
• The Kidney International guideline suggests that ACE inhibitors or ARBs are strongly recommended for moderately-to-severely increased albuminuria (A2 and A3) with diabetes (Grade 1B) 2

Blood Pressure Control

• The American College of Cardiology recommends targeting systolic BP <120 mmHg for most CKD patients 1
• The Annals of Internal Medicine guideline suggests maintaining BP ≤140/90 mmHg for albuminuria <30 mg/24 hours (Grade 1B) 3, 4
• The Annals of Internal Medicine guideline recommends maintaining BP ≤130/80 mmHg for albuminuria ≥30 mg/24 hours (Grade 2D) 3, 4

Statin-Based Cardiovascular Risk Reduction

• The American College of Cardiology recommends moderate-to-high intensity statin therapy for all adults ≥50 years with eGFR <60 mL/min/1.73 m² (CKD G3a-G5) 1

Additional Management Components

• The Kidney International guideline suggests using nonsteroidal mineralocorticoid receptor antagonists (ns-MRA) for adults with type 2 diabetes, eGFR >25 mL/min/1.73 m², normal potassium, and albuminuria >30 mg/g despite maximum tolerated RAAS inhibition (Grade 2A) 2
• The Annals of Internal Medicine guideline recommends targeting HbA1c of 7% for diabetes management 3, 4

Monitoring and Risk Stratification

• The Annals of Internal Medicine guideline suggests monitoring frequency increases with worsening GFR category and albuminuria level 4
• The American College of Cardiology recommends regular risk factor reassessment every 3-6 months 1

Critical Pitfalls to Avoid

• The American College of Cardiology recommends avoiding NSAIDs in CKD due to nephrotoxicity risk and potential for acute kidney injury 1
• The Annals of Internal Medicine guideline suggests avoiding high protein intake (>1.3 g/kg/day) as it accelerates progression 3, 4