Comprehensive CKD Management 2025

Evidence-guided strategies to slow CKD progression, reduce cardiovascular risk, and prepare patients for the right therapy at the right time. Built around the Five Pillars and updated with 2024–2025 trial data and KDIGO guidance.

KDIGO 2024 CKD ADA 2025 Diabetes EMPA-KIDNEY 2022 DAPA-CKD 2020 FIDELIO/FIGARO 2020–21 FLOW 2024

đź’Š Five Pillars: Quick-Start Boxes

1) Blood Pressure & RAAS Blockade Core

  • Target SBP <120 mmHg (standardized office) if tolerated; otherwise <130/80
  • ACEi or ARB first-line for albuminuria (A2–A3), titrate to maximal tolerated
  • Do not stop RAASi for mild creatinine rise (≤30%)—evaluate volume/NSAIDs
  • Use K+ binders (patiromer or SZC) to maintain RAASi if hyperkalemia develops
KDIGO 2024 CKD; STOP-ACEi (2022) continuation data

2) SGLT2 Inhibitors Disease-Modifying

  • Indicated for CKD with albuminuria down to eGFR 20; benefit independent of diabetes
  • Expect transient eGFR dip (≤30%)—this is hemodynamic and typically stabilizes
  • Reduces kidney failure and CV events (DAPA-CKD, EMPA-KIDNEY)
DAPA-CKD 2020; EMPA-KIDNEY 2022

3) Mineralocorticoid Receptor Antagonism (ns-MRA)

  • Finerenone for T2D + CKD with albuminuria on ACEi/ARB—slows CKD and CV events
  • Monitor K+ closely; partner with binders to continue therapy when appropriate
FIDELIO-DKD 2020; FIGARO-DKD 2021; FIDELITY pooled

4) GLP-1 Receptor Agonists

  • For T2D with CKD: improves glycemia, weight, and CV risk
  • FLOW (semaglutide) suggests kidney outcome benefit—guidelines increasingly favor
FLOW 2024; ADA 2025

5) Lifestyle & Risk Factor Optimization

  • Protein ~0.6–0.8 g/kg/day (with dietitian) for A3 proteinuria; avoid malnutrition
  • Sodium <2 g/day; exercise; smoking cessation; vaccination bundle
  • Statins for adults ≥50 with CKD not on dialysis; treat triglycerides case-by-case
KDIGO Nutrition; KDIGO Lipids 2013/updates

🔎 Deep Dives by Topic

Blood Pressure Strategy & RAASi Continuation

Key Point: Standardized BP measurement drives targets; treat to SBP <120 mmHg if tolerated (KDIGO 2024).
  • Start ACEi/ARB for A2–A3 albuminuria regardless of diabetes; up-titrate to albuminuria and BP targets.
  • Accept creatinine rise ≤30% from baseline; evaluate for volume depletion, NSAIDs, renal artery stenosis if >30%.
  • Hyperkalemia management to preserve RAASi: low-K diet counseling, loop diuretics if volume overloaded, chronic binders (patiromer, SZC).
  • Avoid dual RAAS blockade (ACEi + ARB) due to hyperkalemia/AKI risk.
KDIGO 2024; STOP-ACEi 2022; RAASi continuation consensus

SGLT2 Inhibitors

Key Point: Benefits extend to non-diabetic CKD and across eGFR down to ~20.
  • Trials: DAPA-CKD (dapagliflozin), EMPA-KIDNEY (empagliflozin) show reduced CKD progression and CV outcomes.
  • Start at approved doses; counsel on genital mycotic infection risk, sick-day rules, and peri-procedure holds.
  • Do not stop for small early eGFR drops; reassess volume status and concurrent diuretics.
DAPA-CKD 2020; EMPA-KIDNEY 2022

Finerenone (Nonsteroidal MRA)

Key Point: Add to ACEi/ARB in T2D + albuminuric CKD; monitor K+ and eGFR.
  • Reduces CKD progression and CV events; start when K+ ≤4.8 and eGFR ≥25; titrate per label.
  • Combine with K+ binders as needed to maintain therapy without sacrificing RAASi.
FIDELIO-DKD; FIGARO-DKD; pooled FIDELITY

GLP-1 RA in CKD

Key Point: Preferred add-on for T2D with CKD when SGLT2 alone insufficient or not tolerated.
  • Cardiometabolic benefits (weight, BP, A1C); FLOW suggests renal protection with semaglutide.
  • Consider GI tolerability and dose titration; coordinate with nutrition goals.
FLOW 2024; ADA 2025 standards

Potassium Management to Enable Guideline Therapy

  • Patiromer and sodium zirconium cyclosilicate enable continuation of RAASi/finerenone.
  • Choose agent based on onset needs (SZC faster) and chronic control (both effective).
  • Address dietary K+, metabolic acidosis, and diuretic regimen.
Chronic hyperkalemia management consensus; AMETHYST-DN; HARMONIZE

Metabolic Acidosis

  • Treat when serum bicarbonate persistently ≤18–22 mEq/L (threshold varies by guideline and patient context).
  • Oral sodium bicarbonate or base-producing diet slows CKD progression; monitor volume/BP and CO2 levels.
  • Investigational: Non-absorbed HCl binders (e.g., veverimer) show promise but availability varies by region.
KDIGO 2024; UBI and meta-analyses on bicarbonate therapy

Anemia of CKD

  • Replete iron first (oral/IV guided by TSAT and ferritin). Consider IV iron for inflammation or poor absorption.
  • ESAs for symptomatic anemia after iron optimization; target hemoglobin generally 10–11.5 g/dL, avoid normalization.
  • HIF-PH inhibitors: daprodustat approved in the US (non-inferior to ESA in dialysis); others vary by region—assess CV risk profile and indications.
KDIGO Anemia; ASCEND-ND/ID (daprodustat)

CKD-MBD (Mineral and Bone Disorder)

  • Stage-specific approach to Ca, PO4, PTH; avoid routine active vitamin D analogs in non-dialysis unless severe SHPT.
  • Prioritize phosphate control via diet and binders (calcium-free favored when hypercalcemia risk).
  • Calcimimetics mainly in dialysis SHPT; ensure vitamin D sufficiency.
KDIGO CKD-MBD 2017/updates; PRIMO/OPERA

Lipids & Cardiovascular Risk

  • Statin (± ezetimibe) for adults ≥50 with CKD not on dialysis regardless of baseline LDL.
  • Consider PCSK9 inhibitors in very high-risk patients with ASCVD when LDL not at goal.
  • Integrate SGLT2/GLP-1 for additional CV risk reduction.
KDIGO Lipids 2013; ACC/AHA updates

Nutrition, Lifestyle, and Vaccination

  • Dietitian-guided protein restriction; Mediterranean-style patterns with sodium restriction.
  • Exercise, weight management, smoking cessation; alcohol moderation.
  • Vaccines: influenza, pneumococcal, hepatitis B; consider zoster per age/immune status.
KDIGO Nutrition; CDC adult immunization schedule

Referral Timing, Access Planning, and Transplant

  • Refer to nephrology for GFR <30, A3 albuminuria, rapid eGFR decline, refractory HTN/electrolytes, or suspected GN.
  • Pre-ESRD education and modality choice; dialysis access planning when eGFR <20 or rapid decline.
  • Early transplant referral (preemptive preferred) when appropriate.
KDIGO referral criteria; KDOQI access planning

đź“Š KDIGO Heat Map: Risk Stratification

Use GFR category (G1–G5) and albuminuria (A1–A3) to estimate prognosis and guide follow-up intensity, treatment prioritization, and referral.

Remember: Albuminuria is as prognostically important as GFR.

đź”— Cross-Module Links

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For educational purposes only. This content synthesizes major guidelines and trials; always individualize patient care.

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