Treatment & Management (KDIGO, 2024)

The following measures aim to treat the reversible causes of kidney disease, slow its progression, and treat complications.

• Control blood pressure; target systolic blood pressure of less than 120 mmHg, if tolerated

  • Consider less intense target in those that are frail, at high risk for falls, have limited life expectancy, or have symptomatic postural hypotension.
• Evidence-based pharmacologic treatments that delay the progression of CKD (KDIGO, 2024)
  • Renin-angiotensin-system inhibitors (RASi) are beneficial in decreasing blood pressure, reducing mortality in heart failure, decreasing proteinuria, and slowing progressive loss of kidney function in patients with CKD and include:
    • Angiotensin-coverting enzyme inhibitors (ACEi) and
    • Angiotensin II receptor blockers (ARB)
  • Initiate therapy with a RASi in patients with CKD, with and without diabetes and with moderately to severely increased albuminuria
  • Avoid combination of ACEi, ARB, and direct renin inhibitors in those with CKD with and without diabetes
• Initiate therapy with SGLT2i in patients with type 2 diabetes, CKD, and an eGFR greater than or equal to 20 mL/min per 1.73 m²
• Initiate therapy with an SGLT2i in CKD patients without diabetes if the patient has
  • eGFR greater than or equal to 20 mL/min per 1.73 m² with ACR greater than or equal to 200 mg/g
  • eGFR 20 to 45 mL/min per 1.73 m² with ACR less than 200 mg/g
  • heart failure (regardless of albuminuria)
• Initiate therapy with a mineralocorticoid receptor antagonist (MRA) in patients with type 2 diabetes, an eGFR greater than 25 mL/min per 1.73 m², normal serum potassium concentration, and albuminuria (greater than 30 mg/g) despite maximum tolerated dose of a RASi
• Manage diabetes (KDIGO, 2024).
  • Individualized target hemoglobin A1c from < 6.5 to < 8% in patients with CKD not treated with dialysis with goal to avoid hypoglycemia
  • Accuracy of hemoglobin A1C may decline in those being treated with dialysis
• Measure hemoglobin to monitor for anemia. Assess for iron deficiency anemia and treat with iron supplementation accordingly.
• Monitor serum potassium level. Potassium-sparing medications, dietary intake, insulin deficiency, and metabolic acidosis can increase the risk of hyperkalemia in patients with CKD.
• Encourage smoking cessation.
• Encourage weight reduction.
• Encourage moderate intensity physical activity for at least 150-minutes/week if tolerated
• Temporarily discontinue nephrotoxic and renally excreted medications if GFR less than 60 mL/min/1.73m² and increased risk of AKI (KDIGO, 2024; Norton et al., 2017a) such as non-steroidal anti-inflammatory drugs (NSAIDS), diuretics, metformin, lithium, digoxin, quinolones, B-lactam antibiotics, sulfonamides.Adjust drug doses for the level of GFR. Examples of common drugs requiring renal dose adjustments include allopurinol, lithium, acyclovir, gabapentin, rivaroxaban (Xarelto), cephalexin, Bactrim, amoxicillin, and levofloxacin. Metformin is contraindicated in patients with an eGFR below 30 mL/min/1.73 m².
• Refer to specialist kidney care services.

• Adaptation of a healthy and diverse diet with higher consumption of plant-based food compared to animal-based foods.
• Restrict salt intake (KDIGO, 2024).
  • Goal is less than 90 mmol (2 grams/day), unless contraindicated.
• Modify protein intake (KDIGO, 2024).
  • Maintain protein intake of 0.8 grams/kg body weight per day.
  • Avoid high protein intake (greater than 1.3 g/kg/day) in adults with CKD at risk of progression.
• Avoid foods high in potassium, phosphorus, and sodium.
• Restrict fluid intake based on urine production.
• Weight loss counseling in those with obesity and CKD.
• Older adults with frailty and sarcopenia may require higher protein and calorie targets.

Kidney replacement therapy (KRT) (Norton et al., 2017b)

Hemodialysis

• In patients with CKD, an optimial eGFR in the absence of symptomatic kidney disease has not been established.
• Initiate in patients with CKD when one or more of the following are present (KDIGO, 2024):
  • Signs or symptoms of kidney failure (neurological signs and symptoms attributable to uremia, pericarditis, anorexia, medically resistant acid-based or electrolyte abnormalities, intractable pruritus, or serositis)
  • Inability to control volume status or blood pressure
  • Progressive decrease in nutritional status unresponsive to dietary intervention
• Consider planning for dialysis access and/or kidney transplantation in adults when GFR is less than 15-20 mL/min/1.73m² or risk for kidney replacement therapy (KRT) is greater than 40% over 2 years.
• Dialysis machine is used to filter waste products from the blood three or more times a week; diffusion efficacy depends on the dialysate solution.
• Hemodialysis can be performed at in-center locations or at home.
• Vascular access required
  • Arteriovenous fistula: an artificial connection between an artery and vein diverting blood to the vein; preferred access method
  • Arteriovenous graft: second option if fistula cannot be created
  • In an emergency, temporary vascular access may be obtained in a central vein (i.e., internal jugular) however these are associated with inadequate dialysis, increased infection rates, clotting, and inflammation.

• The peritoneal membrane is used as a semipermeable filter, replacing the kidneys. A dialysis solution (osmotic agent) is infused into the abdominal cavity through a percutaneous catheter. Through diffusion, waste products are pulled from the blood in the peritoneal capillaries into the dialysate. Following the prescribed dwell time, the solution is drained through the catheter.

• Efficacy is based on:
  • Concentration gradient
  • Size of the solute
  • Permeability of the peritoneal membrane
• Restrict potassium intake.
• Replace amino acids.
• Increase dietary proteins.
• Monitor glucose closely; insulin may be added to dialysis solution.

• All patients with CKD G4-G5 who are expected to reach end-stage kidney disease, in the absence of a systemic end-stage disease (multiple myeloma, advanced extrarenal amyloidosis, decompensated cirrhosis, severe irreversible obstructive or restrictive lung disease, or severe uncorrectable cardiac disease) should be informed of, educated about, and considered for kidney transplantation regardless of socioeconomic status, sex, gender identity, or race/ethnicity.
• Refer candidates at least 6 to 12 months before anticicpated dialysis and those on dialysis when medically stable and kidney failure deemed irreversible.
• Renal transplant is associated with the best quality of life and survival. Pretransplant evaluation is extensive and varies from facility to facility.

• Option for people who choose not to pursue KRT
• Advance care planning and end-of-life care
• Include protocols for dietary restrictions, symptom and pain management, psychological care, spiritual care, culturally sensitive care and bereavement support.