Chronic Kidney Disease Management

Risk Assessment and Referral

The Kidney International guideline recommends using externally validated risk equations to estimate absolute risk of kidney failure in CKD G3-G5, with a 5-year kidney failure risk of 3-5% determining need for nephrology referral, a 2-year kidney failure risk >10% determining timing for multidisciplinary care, and a 2-year kidney failure risk >40% guiding KRT preparation planning 1
Older adults with CKD stage 3B-5 have a 3.5-fold increased risk of mortality compared to those with stages 1-2, and CKD in older adults is associated with a higher risk of acute kidney injury, and dehydration and nephrotoxins should be avoided 2

The Kidney International guideline strongly recommends RASi (ACEi or ARB) for patients with CKD and moderately-to-severely increased albuminuria (G1-G4, A2 and A3) with diabetes (1B) 3
The Kidney International guideline suggests RASi for patients with CKD and moderately increased albuminuria (G1-G4, A2) without diabetes (2C) 3
The Kidney International guideline recommends treating patients with type 2 diabetes, CKD, and eGFR ≥20 ml/min/1.73 m² with an SGLT2i (1A) 3
The Kidney International guideline recommends treating adults with CKD having eGFR ≥20 ml/min/1.73 m² with urine ACR ≥200 mg/g or heart failure with an SGLT2i (1A) 3
The Kidney International guideline recommends treating adults ≥50 years with eGFR <60 ml/min/1.73 m² with statin or statin/ezetimibe (1A) 3
Statin therapy is recommended for adults over 50 years with eGFR <60 ml/min/1.73 m² 1, 3
Aspirin is recommended for secondary prevention of cardiovascular disease in patients with established cardiovascular disease 1, 3
Anticoagulation therapy is recommended for patients with atrial fibrillation, with preference for direct oral anticoagulants (DOACs) over vitamin K antagonists in CKD stages G1-G4 3

The Kidney International guideline recommends moderate-intensity physical activity for at least 150 minutes per week (1D) 1
The Kidney International guideline advises patients to avoid sedentary behavior 1
The Kidney International guideline encourages children with CKD to achieve 60 minutes of daily physical activity 1
The Kidney International guideline advises healthy and diverse diets 1

The Kidney International guideline recommends statin therapy, blood pressure management, and antiplatelet therapy for established cardiovascular disease 3
The American College of Cardiology recommends that the level of care for cardiovascular disease should not be compromised by the presence of CKD 2
Blood pressure treatment should be carefully tailored in elderly patients, with gradual escalation of treatment, regular monitoring for postural hypotension, and close attention to adverse events including electrolyte disorders and acute kidney function deterioration 4

The Kidney International guideline recommends management of anemia, mineral and bone disorders, acidosis, and potassium abnormalities in CKD patients 3
The Kidney International guideline recommends monitoring kidney function and albuminuria at least annually, with more frequent monitoring for those at higher risk of progression, in patients with CKD stage 3b, particularly elderly females 4, 2
Blood pressure control targets are ≤140/90 mmHg for albuminuria <30 mg/24h and ≤130/80 mmHg for albuminuria ≥30 mg/24h, as recommended by the Kidney International guideline and supported by 2, 5
Annual monitoring of kidney function and albuminuria is recommended, along with control of cardiovascular risk factors and avoidance of nephrotoxins 2
Serum creatinine alone is an unreliable marker of kidney function in older adults due to reduced muscle mass, and cystatin C-based equations may be more accurate in this population 6

The American Journal of Kidney Diseases guideline recommends providing primary supportive care based on need rather than survival estimation, and comprehensive conservative care should be implemented, including interventions to delay kidney disease progression, active symptom management, shared decision-making, advance care planning, and psychosocial support 7, 2
Consider deprescribing potentially inappropriate medications to reduce pill burden, as suggested by the Kidney International guideline 8
Medication dosages should be adjusted based on kidney function, according to the Circulation guideline 9