Chronic Kidney Disease Management

Introduction

Chronic Kidney Disease (CKD) management involves a comprehensive approach to slow disease progression and reduce mortality, as recommended by the Kidney International guideline society 1, 2

Blood Pressure Control

The American College of Physicians recommends blood pressure control, use of renin-angiotensin system inhibitors, lifestyle modifications, and management of comorbidities to slow disease progression and reduce mortality in patients with CKD 3
The target blood pressure for patients without albuminuria should be <140/90 mmHg, and for patients with albuminuria (≥30 mg/24 hours) or diabetes, it should be <130/80 mmHg, as recommended by the Kidney International guideline society, American Heart Association, and Kidney International 2, 4, 5, 6
Optimize blood pressure control with ACE inhibitors or ARBs, using SGLT2 inhibitors in diabetic kidney disease, and implementing lifestyle modifications including reduced sodium intake, as recommended by the American Diabetes Association 7, 8

Medication Management

The National Kidney Foundation recommends ACE inhibitors or ARBs as first-line medications for patients with albuminuria >30 mg/24 hours 3, 1
The American College of Physicians recommends ACE inhibitors or ARBs as first-line therapy for patients with albuminuria >30 mg/day, and should be continued unless serum creatinine rises by more than 30% within 4 weeks, as recommended by the Kidney International guideline society 2, 8
The American Diabetes Association recommends SGLT2 inhibitors for patients with type 2 diabetes and CKD with eGFR ≥20 mL/min/1.73 m², especially with albuminuria ≥200 mg/g creatinine 9
The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines support the use of finerenone, a non-steroidal mineralocorticoid receptor antagonist, in reducing CKD progression, cardiovascular risks, and death in patients with diabetic kidney disease 9

Lifestyle Modifications

The American College of Cardiology recommends maintaining a protein intake of 0.8 g/kg body weight/day in adults with CKD G3-G5 1
The American Heart Association recommends restricting sodium intake to <2 g of sodium per day (<5 g salt/day) 1
The National Kidney Foundation recommends considering a plant-based "Mediterranean-style" diet 10
Undertake moderate-intensity physical activity for at least 150 minutes per week, adjusted to cardiovascular and physical tolerance, as recommended by the Kidney International guideline and the American Journal of Kidney Diseases 1, 11, 10
Adopt healthy and diverse diets with higher consumption of plant-based foods compared to animal-based foods, and maintain protein intake of 0.8 g/kg body weight/day in adults with CKD G3-G5, as recommended by the Annals of Internal Medicine, Academy of Nutrition and Dietetics, and Kidney International guidelines 12, 11, 10
Completely avoid tobacco products, as recommended by the Kidney International guideline, American Lung Association, and KDIGO guideline 1, 13, 12, 10

Lipid Management

The American College of Cardiology recommends statin or statin/ezetimibe combination for adults ≥50 years with eGFR <60 ml/min/1.73 m² 10
The American Heart Association recommends statin therapy for adults ≥50 years with eGFR ≥60 ml/min/1.73 m² 10
The National Lipid Association recommends considering statin therapy for adults 18-49 years with CKD if they have coronary disease, diabetes, prior stroke, or 10-year CV risk >10% 10

Monitoring and Assessment

Quantitatively assess urinary albumin (e.g., urine albumin-to-creatinine ratio) and eGFR at least annually in all patients with type 2 diabetes and patients with type 1 diabetes duration of ≥5 years, as recommended by Kidney International 7
Confirm CKD diagnosis by identifying persistent abnormalities in either urine albumin-to-creatinine ratio or eGFR for >3 months, according to Kidney International 14
Evaluate albuminuria by measuring ACR in a random spot urine collection, as suggested by the American Diabetes Association 15

Use validated risk prediction models that incorporate eGFR and albuminuria to guide preventive therapies, with the KDIGO heat map categorizing risk based on eGFR and albuminuria levels, as follows:

Color	Risk Level	Corresponding Categories
Green	Low	G1A1, G2A1
Yellow	Moderately elevated	G1A2, G2A2, G3aA1
Orange	High	G1A3, G2A3, G3aA2, G3bA1
Red	Very high	G3aA3, G3bA2, G3bA3, G4A1, G4A2, G4A3, G5A1, G5A2, G5A3	[10, 1, 16]

Monitor eGFR and albuminuria regularly based on risk category, with the following monitoring frequency:

GFR Category	Albuminuria Category	Monitoring Frequency
G1-G2	A1	Annual
G3a	A1	1-2 times per year
G1-G2	A2	1-2 times per year
G4-G5	A1-A3	3-4 times per year
Any	A3	3-4 times per year	[10, 1, 17]

Symptom Management

Regular symptom assessment and management using validated tools, such as the Edmonton Symptom Assessment System-revised: Renal (ESAS-r:Renal) or Palliative Care Outcome Scale-Renal (POS-renal), is essential for providing comprehensive care to patients with CKD 18
Common CKD symptoms requiring management include pain/discomfort, lack of energy/fatigue, sleep-related problems, itching/skin problems, depressive symptoms, and restless legs syndrome, with depressive symptoms affecting 26.5% of CKD patients in stages 1-4 and 39.3% in dialysis patients 18
Consider low-dose pharmacological therapy that may have efficacy across several symptoms, and opioid use in CKD patients requires careful monitoring for efficacy and safety, as no long-term studies exist 18

Mineral and Bone Disorder Management

Monitor and manage phosphate, calcium, PTH, and vitamin D levels to prevent CKD-mineral bone disorder (CKD-MBD), with consideration of oral bicarbonate supplementation for serum bicarbonate <22 mmol/L to manage metabolic acidosis, as recommended by the KDIGO guideline 1

Anemia Management

Evaluate iron status before and during treatment, and administer supplemental iron when serum ferritin is <100 mcg/L or transferrin saturation <20%, as recommended by the KDIGO guideline 10

Patient-Centered Care

Perform shared decision-making to understand the patient's values, priorities, and goals of care, and document the patient's decision in advance directives and medical orders as appropriate, according to the American Journal of Kidney Diseases guidelines 19, 20
Provide access to resources for advance care planning, as recommended by the American Journal of Kidney Diseases 20
Consider patient-reported outcome measures (PROMs) to assess treatment effectiveness, and adjust treatment based on symptom response and patient priorities, as recommended by 21
Clinicians should focus on patient-centered care, considering symptoms and daily activities, rather than just laboratory results, as noted by 21