CKD Management Medtweetorial

Introduction

CKD is classified based on the GFR and albuminuria. Based on the GFR (Figure 1), it can be divided into five stages: G1 (GFR ≥ 90 mL/min/1.73 m²), G2 (GFR 60–89), G3 (subdivided into G3a with a GFR 45 to 59 and G3b with a GFR 30–44), G4 (GFR 15–29), and G5 (GFR < 15 not on renal replacement therapy).

In CKD, starting dialysis based only on a target GFR doesn't improve survival rates. Dialysis should begin before the patient's metabolic or nutritional status deteriorates.

Figure 1

Stages of chronic kidney disease.

Patients are usually asymptomatic until significant renal function is lost (late stage G4 and stage G5). However, complications including hypertension, anemia, and mineral bone disorders (renal osteodystrophy and secondary hyperparathyroidism) often develop during stage G3 and thus should be investigated and addressed before patients become symptomatic. Let's dive into key treatment strategies, abbreviations, and guidelines for effective CKD care!

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Management approach

Diet in CKD

• Sodium < 2g/d (see "Sodium-Restricted Diet") for CKD + hypertension, heart failure, or refractory hypertension.
• Fluid restriction: usually not needed; avoid in dilutional hyponatremia.
• Protein: no strict restriction to slow CKD progression.
• 🍌🍅🥔🍊 (Tomato-based products, bananas, potatoes) high in potassium; restrict to 60 mEq/d in hyperkalemia.
• 🥛🥤🥩 Dairy products, dark colas, nuts and processed meat should be avoided in hyperphosphatemia; phosphate binders if needed (see "How to choose PHOSPHATE binder for CKD patients").
• See "Nutrition for patients with CKD" - edited by Dr. Mahitab Hany.

Smoking & CKD

• Accelerates CKD progression.
• Counseling essential for tobacco cessation.

Hypertension

• Target BP < 120 mmHg (2021 KDIGO).
• ACEi/ARBs preferred (see "How to safely use ACEIs or ARBs in patients with chronic kidney disease"); monitor Cr, K+ after dose change.
• Diuretics useful for euvolemia; thiazides become less effective as eGFR < 30 mL/min, loop diuretics effective.

Albuminuria & Proteinuria

• BP control & RAAS inhibition specifically ↓ albuminuria & CKD progression.
• See "Statins can prevent proteinuria in patients with hypertension".

Metabolic Acidosis

• Alkaline buffer release ↑ bone issues.
• Oral bicarbonate tablets (650 or 1300 mg BID or TID) to keep serum bicarbonate ≥ 22 mEq/L.

Hyperlipidemia

• Statins+ezetimibe ↓ CV events in CKD (see "Optimization of lipids in CARDIOvascular patients"); KDIGO 2014 recommendations.
• See "Diet for Dyslipidemia" - edited by Dr. Mahitab Hany.
• See "Think LOWER IS BETTER for LDL in high CV risk patients".
• See "How to deal with statin interaction?".

Diabetes

• HbA1C target 7% (see "Personalize glycemic targets for patients with diabetes").
• SGLT2 inhibitors: reno-protective, CV benefits (GFR ≥ 30 mL/min/1.73 m²) - (see "Optimize management of CKD in patients with diabetes").

Anemia

• Common in GFR < 60 mL/min/1.73 m².
• Check iron stores; IV iron if TSAT ≤ 30% & no iron overload.
• ESA use cautiously; monitor Hb every 3 months. See "Erythropoietin (EPO) dosing in anemia of CKD".
• See "Overview of anemia".

Mineral Bone Disorders

• CKD-bone mineral disorders ↑ with GFR < G3.
• Aim: suppress PTH, maintain Ca & phosphate.
• VitD repletion: use ergocalciferol 50,000-IU weekly or cholecalciferol 2000–4000 IU daily if deficient 25-OH vitD (< 30 ng/mL). Severe deficiency (< 5 ng/dL) needs 12+ weeks. Maintenance: monthly ergocalciferol 50,000 IU or daily cholecalciferol 1000–2000 IU (see "Vitamin D deficiency in adults" - edited by Dr. Maha Khalifa)
• Phosphate binders (to control Phosphate); active vitD (calcitriol 0.25–1 μg).

Prep for Renal Replacement

• Early counseling on hemodialysis, peritoneal dialysis, transplantation.
• Protect veins; timely referral for AV access.
• Immunizations: Hep B vaccine recommended if eGFR < 30 mL/min/1.73 m², pneumococcal for all CKD.

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References

1. Cooper BA, Branley P, Bulfone L, et al. A randomized, controlled trial of early versus late initiation of dialysis. N Engl J Med. 2010;363:609-619.
2. Parsa A, Kao WHL, Xie D, et al. APOL1 risk variants, race, and progression of chronic kidney disease. N Engl J Med. 2013;369(23):2183-2196.
3. Kidney Disease: Improving Global Outcomes (KDIGO) Blood Pressure Work Group. KDIGO 2021 clinical practice guideline for the management of blood pressure in chronic kidney disease. Kidney Int. 2021;99(3S):S1-S87.
4. Fried LF, Emanuele N, Zhang JH, et al. Combined angiotensin inhibition for the treatment of diabetic nephropathy. N Engl J Med. 2013;369:1892-1903.
5. Hultin S, Hood C, Campbell KL, et al. A systematic review and meta-analysis on effects of bicarbonate therapy on kidney outcomes. Kidney Int Rep. 2020;6(3):695-705.
6. Baigent C, Landray MJ, Reith C, et al. The effects of lowering LDL cholesterol with simvastatin plus ezetimibe in patients with chronic kidney disease (Study of Heart and Renal Protection): a randomised placebo-controlled trial. Lancet. 2011;377:2181-2192.

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