Chronic Kidney Disease Management Guidelines

Introduction to CKD Management

The American College of Cardiology recommends a comprehensive treatment strategy for managing chronic kidney disease, targeting blood pressure control, cardiovascular risk reduction, lifestyle modifications, and monitoring for complications to reduce the risk of disease progression and associated morbidity and mortality 1

The Kidney Disease: Improving Global Outcomes (KDIGO) guideline recommends 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 2, 1
Establish the cause of CKD using clinical context, personal and family history, 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 Heart Association recommends targeting systolic blood pressure of <120 mm Hg when tolerated, using standardized office BP measurement 3
Consider less intensive BP-lowering therapy in people with frailty, high risk of falls and fractures, limited life expectancy, or symptomatic postural hypotension 3
In children with CKD, aim for 24-hour mean arterial pressure by ambulatory blood pressure monitoring to be ≤50th percentile for age, sex, and height 3
Monitor BP once a year with ambulatory blood pressure monitoring and every 3–6 months with standardized office BP in children with CKD 3

The World Health Organization recommends advising people with CKD to undertake moderate-intensity physical activity for at least 150 minutes per week, adjusted to their cardiovascular and physical tolerance 3, 4
Encourage patients to avoid sedentary behavior 3, 4
Consider advising people with obesity and CKD to lose weight 3, 4
Encourage children with CKD to undertake physical activity aiming for ≥60 minutes daily and to achieve a healthy weight 3, 4
Promote smoking cessation and abstinence from tobacco products 2

The Academy of Nutrition and Dietetics recommends advising adoption of healthy, diverse diets with higher consumption of plant-based foods compared to animal-based foods and lower consumption of ultra-processed foods 3, 4
Maintain protein intake at 0.8 g/kg body weight/day in adults with CKD G3–G5 3, 4
Avoid high protein intake (>1.3 g/kg body weight/day) in adults with CKD at risk of progression 3, 4
In motivated adults with CKD at risk of kidney failure, consider prescribing a very low-protein diet (0.3–0.4 g/kg body weight/day) supplemented with essential amino acids or ketoacid analogs under close supervision 3, 4
Limit sodium intake to <2 g per day (or <5 g of sodium chloride per day) 3, 4

The American College of Cardiology recommends prescribing statins or statin/ezetimibe combination for adults ≥50 years with eGFR <60 ml/min/1.73 m² (CKD G3a-G5) 2, 1
Choose statin regimens that maximize absolute reduction in LDL cholesterol 5
Consider prescribing PCSK-9 inhibitors for people with CKD who have an indication for their use 5
Recommend oral low-dose aspirin for secondary prevention in people with CKD and established ischemic cardiovascular disease 5

The European Society of Cardiology recommends using non-vitamin K antagonist oral anticoagulants (NOACs) in preference to vitamin K antagonists for thromboprophylaxis in atrial fibrillation in people with CKD G1–G4 5
Adjust NOAC dose based on GFR, with caution needed at CKD G4–G5 5

The National Kidney Foundation recommends considering GFR when dosing medications cleared by the kidneys 2
For most clinical settings, validated eGFR equations using serum creatinine are appropriate for drug dosing 2
Perform thorough medication review periodically and at transitions of care to assess adherence, continued indication, and potential drug interactions 2

The Kidney Disease: Improving Global Outcomes (KDIGO) guideline recommends referring 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) 2
Refer adults with CKD to specialist kidney care services when they have persistent hematuria 2
Refer adults with CKD to specialist kidney care services when they have any sustained decrease in eGFR 2

The European Renal Association recommends treating symptomatic hyperuricemia (gout) with urate-lowering therapy, preferring xanthine oxidase inhibitors over uricosuric agents 6
Provide pharmacological treatment with or without dietary intervention to prevent acidosis (serum bicarbonate <18 mmol/L) 6
Monitor treatment to ensure serum bicarbonate doesn't exceed normal limits and doesn't negatively impact blood pressure, serum potassium, or fluid balance 6