Definition

• CKD = GFR < 60 or kidney damage (proteinuria, hematuria, imaging abnormal, electrolyte abnormality 2/2 to renal) for > 3 months

Diagnosis and workup

• Lab studies: CBC, CMP, lipid panel, uric acid
• Urine studies: UA with microscopy, urine sediment exam, spot UProt/Cr, CBC (for CKD-related anemia)
• Renal US: in CKD usually shows echogenic, small kidneys bilaterally (some exceptions are DM, myeloma, HIV, amyloid, PCKD).
• If age >50 with proteinuria or anemia, consider SPEP/UPEP/IFE (or serum free light chains instead of SPEP/UPEP/IFE)

Classification

Classification should focus on AGC: (1) Albuminuria, (2) GFR, (3) Cause

Management

Prevention of CKD progression

• Avoid nephrotoxic agents such as NSAIDs, PPIs, contrast studies, aminoglycosides, acyclovir, phosphate-based bowel prep, and baclofen
• Renally dose medications, including antimicrobials, atenolol, colchicine, DOACs, diabetes medications, gabapentin, levetiracetam, metoclopramide, and opioids
• Encourage regular exercise and smoking cessation.
• Treat underlying hepatitis C virus (HCV) infection.

Management of co-morbidities

• Blood pressure:
• Treat BP to goal < 130/80 (AHA 2017) or <120 SBP (KDIGO 2021)
• In resistant hypertension with HFrEF, consider spironolactone
• Proteinuria:
• For patients with A2 albuminuria (UACR >300 mg/d) → start ACEi/ARBs with the goal of reducing UACR to <300 mg/d.
⚠️
An rise in Cr 20-30% can be expected when starting ACEi/ARBs. Recheck labs within 1 week to confirm that the Cr does not continue to increase
• SGLT2 inhibitors are recommended if GFR >20 mL/min/1.73 m², as they have been shown to slow CKD progressionExpect a slight decline in GFR here too, this is acceptable
• Diabetes:
• Aim for an HbA1c <7%;
• Continue metformin if GFR >45
• Start SGLT2 inhibitors if GFR >20
• GLP-1 receptor agonists if GFR >30
• Insulin is safe at any GFR
• ASCVD:
• Prescribe statin therapy for patients aged 50 years or older or if ASCVD risk is 10% or greater

Lifestyle and nutrition

• For CKD stages G3-G5 with serum phosphate >5.5 mg/dL, dietary phosphate should be restricted to 0.55-0.60 g/kg/day.
• In CKD stages G4-G5, advise patients to avoid high-potassium foods.
• Refer to a renal dietitian for personalized nutrition planning.
• For patients with nephrotic syndrome and CKD stages G3-G5, protein supplementation should be 0.6-0.8 g/kg/day
• Prescribe vitamin B complex (Nephrovite, Nephrocaps, Triphrocaps) to provide essential vitamins
• If edema is present, recommend fluid restriction and a sodium intake of less than 2 g/day.

Management of CKD complications

• Metabolic acidosis: Prescribe sodium bicarbonate 650-1300 mg TID (or 0.5 meq/kg/day) to maintain serum bicarbonate >22 mmol/L.
• Anemia: Dx of exclusion. Check Hgb q3 months if anemic, not on HD and not on erythropoiesis-stimulating agents (ESAs). ESAs if Hb <10 with a target Hgb of 10-11.5 g/dL. Reasonable to trial PO iron if %sat <30 and ferritin < 500 and anemic.
• Bone mineral Disease (BMD): treat to iPTH goal < 9x ULN
• Rx: Phosphate binder and ergocalciferol (goal 30)
• Hold Vit D if corr Ca > 10.2 or phos > 4.6
• Up to Stage IV: iPTH goal ULN
• iPTH goal
• Measure Ca, Phos q3 months
• Initiate phosphate binders such as sevelamer 800 mg TID with meals to maintain serum phosphate <5.5 mg/dL
• Hyperkalemia: Use loop diuretics or potassium binders like sodium zirconium cyclosilicate (Lokelma) as needed.
• Edema: Manage with diuretics as needed or on a standing basis.

Other considerations

• In stage 4-5 CKD, avoid venipuncture, IV placement, PICC lines, and subclavian catheters in arm most suitable for future vascular access (usually non-dominant arm)
• Pneumococcal vaccine (both PPS-23 and PCV-13) should be administered once, at least one year apart, and yearly flu vaccine. Hepatitis B vaccination if progressing to dialysis and/or transplantation.

Indications for referral to nephrology

• CKD Stage G3b
• Gradual progression: >25% decline in GFR or >5/yr annual decline
• AKI or sudden sustained drop in GFR
• Proteinuria > 300 mg/day or equivalent
• Unexplained persistent hematuria >20 / hpf or RBC casts
• Refractory HTN on 4 agents with CKD
• Persistent electrolyte abnormalities
• Recurrent nephrolithiasis
• Hereditary kidney disease

On this page

• Definition
• Diagnosis and workup
• Classification
• Management
• Prevention of CKD progression
• Management of co-morbidities
• Lifestyle and nutrition
• Management of CKD complications
• Other considerations
• Indications for referral to nephrology

Resources

Guidelines

KDIGO guidelines focus on topics related to the prevention or management of individuals with kidney diseases.

kdigo.org

Website: Navigation

Outpatient Guide

‣

Addiction Medicine

Opioid Use Disorder (OUD)

‣

Nephrology

Chronic Kidney Disease (CKD)

‣

Pulmonology

Asthma