Last updated March 14, 2022

Management of Chronic Kidney Disease

Recommendations

Diagnosis Assessment and Lab Monitoring

In the general population, there is insufficient evidence to recommend for or against periodic evaluation for chronic kidney disease. ()
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When screening or stratifying risk for chronic kidney disease, we recommend including urine albumin-to-creatinine ratio testing in addition to estimated glomerular filtration rate to optimize the diagnosis and staging of chronic kidney disease. (Strong for)
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In patients with an estimated glomerular filtration rate <60 mL/minute/1.73 m², we suggest one-time cystatin C-based estimated glomerular filtration to confirm diagnosis and/or refine staging of chronic kidney disease. (Weak for)
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We suggest the use of a validated risk prediction model as a clinical decision support aid in the management of patients with chronic kidney disease. (Weak for)
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When assessing the risk of progression to end-stage renal disease, there is insufficient evidence to recommend a specific risk prediction calculator. ()
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General Management Strategies

Team Management and Education

There is currently insufficient evidence to recommend a specific threshold of risk, renal function, or proteinuria to refer patients for a nephrology evaluation and management of chronic kidney disease. ()
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We suggest interdisciplinary care (including dietitians, pharmacists, and social workers in addition to physicians and nurses) for patients with later-stage chronic kidney disease. (Weak for)
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When providing patient education, there is insufficient evidence to recommend for or against a particular health education program, mode, or modality to prevent chronic kidney disease progression. ()
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For patients who are at high risk for requiring hemodialysis/renalreplacement and need long-term venous access, we suggest against peripherally inserted central catheter (PICC) lines to optimize future dialysis vascular access options, while considering patient values and preferences. (Weak against)
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Indication for Referral to Nephrology for Renal Replacement Therapy Including Dialysis and Renal Transplant

We suggest utilizing shared decision making regarding renal replacement therapy (versus conservative management) in part to improve patient satisfaction. (Weak for)
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In patients with high comorbidities/low functional status approaching the need for renal replacement therapy and for whom prolongation of life is the priority, we suggest evaluation for renal replacement therapy with sufficient time for comprehensive preparation. (Weak for)
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In patients with high comorbidities/low functional status approaching the need for renal replacement therapy and for whom avoiding hospitalization, death in hospitals, or intensive procedures is the priority, we suggest offering conservative management over dialysis. (Weak for)
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In patients with high comorbidities/low functional status approaching the need for renal replacement therapy and for whom prolongation of life may not be the priority, there is insufficient evidence to recommend for or against dialysis to improve quality of life. ()
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Non-pharmacological Management of CKD

We suggest the use of dietary sodium restriction as a self-management strategy to reduce proteinuria and improve blood pressure control in patients with chronic kidney disease. (Weak for)
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In selected patients with stage 3 and 4 chronic kidney disease, we suggest offering a dietary protein intake of 0.6 to 0.8 g/kg/day as it may slow the decline in estimated glomerular filtration rate and progression to end-stage renal disease. (Weak for)
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Pharmacologic Management of CKD & Associated Conditions

Diabetes Medications

We suggest offering metformin as a first-line therapy for the treatment of type 2 diabetes in patients with stage 1 to 3 chronic kidney disease to reduce all-cause mortality. (Weak for)
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We recommend offering sodium-glucose co-transporter 2 inhibitors as an option for add-on therapy for the treatment of type 2 diabetes in patients with stage 1 to 3 chronic kidney disease to reduce chronic kidney disease progression and the risk of cardiovascular events. (Strong for)
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We suggest offering liraglutide or dulaglutide (glucagon-like peptide1 receptor agonists) as an option for add-on therapy for the treatment of type 2 diabetes in patients with chronic kidney disease to reduce chronic kidney disease progression. (Weak for)
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In patients with chronic kidney disease and type 2 diabetes, there is insufficient evidence to recommend for or against the use of thiazolidinediones or dipeptidyl peptidase-4 inhibitors to decrease progression of chronic kidney disease or mortality. ()
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Hypertension Medications

We suggest intensive blood pressure management (insufficient evidence to recommend a specific target) beyond a target of less than 140/90 mmHg, to reduce mortality in patients with estimated glomerular filtration rate below 60 mL/minute/1.73 m². (Weak for)
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In patients with non-diabetic chronic kidney disease, hypertension, and albuminuria, we recommend the use of an angiotensin-converting enzyme inhibitor to prevent progression of chronic kidney disease. Angiotensin II receptor blockers may be substituted for patients with an angiotensin-converting enzyme-inhibitor-induced cough. (Strong for)
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In patients with chronic kidney disease, diabetes, hypertension, and albuminuria, we recommend the use of an angiotensin-converting enzyme inhibitor or angiotensin II receptor blockers to slow the progression of chronic kidney disease, unless there is documentation of intolerance. (Strong for)
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We recommend against the use of combination renin-angiotensin-aldosterone system blockade (an angiotensin-converting enzyme inhibitor and angiotensin II receptor blocker, or an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker with a direct renin inhibitor) in patients with chronic kidney disease. (Strong against)
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Anemia Medications

We suggest initiation of oral iron therapy to support iron requirements in patients with chronic kidney disease. (Weak for)
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We recommend against initiating erythropoiesis-stimulating agents in patients with chronic kidney disease for the purpose of achieving a hemoglobin target above 11.5 g/dL due to increased risk of stroke and hypertension. (Strong against)
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We recommend against initiating erythropoiesis-stimulating agents at a hemoglobin level greater than 10 g/dL. (Strong against)
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Bone Health Medications

We suggest against offering calcitriol or active vitamin D analogs to patients with stage 3 and 4 chronic kidney disease and elevated parathyroid hormone levels. (Weak against)
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We suggest against offering calcimimetics to patients with stage 3 and 4 chronic kidney disease and elevated parathyroid hormone levels. (Weak against)
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There is insufficient evidence to recommend for or against the use of phosphate binders to reduce mortality, progression of chronic kidney disease, or major cardiovascular outcomes in patients with stage 2 to 5 chronic kidney disease. ()
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Other Medications to Slow CKD Progression

We suggest the use of bicarbonate supplementation in chronic kidney disease patients with metabolic acidosis to slow the progression of chronic kidney disease. (Weak for)
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In patients with chronic kidney disease and asymptomatic hyperuricemia, there is insufficient evidence to recommend for or against the use of urate-lowering therapy for the purpose of slowing progression of chronic kidney disease. ()
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In patients at risk for rapidly progressing autosomal dominant polycystic kidney disease, we suggest offering tolvaptan in consultation with a nephrologist to slow decline in estimated glomerular filtration rate. (Weak for)
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Contrast-Associated Kidney Injury Management

For patients at increased risk for iodinated contrast-associated acute kidney injury, we recommend volume expansion with intravenous isotonic saline prior to and following iodinated contrast administration. (Strong for)
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We recommend against the administration of N-acetylcysteine for prevention of iodinated contrast-associated acute kidney injury. (Strong against)
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We recommend against the use of renal replacement therapy for iodinated contrast-associated acute kidney injury prophylaxis. (Strong against)
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Recommendation Grading

Overview

Title

Management of Chronic Kidney Disease

Authoring Organization

Publication Month/Year

April 1, 2020

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Male, Adult, Older adult

Health Care Settings

Operating and recovery room, Outpatient

Intended Users

Dietician nutritionist, epidemiology infection prevention

Scope

Management, Treatment

Diseases/Conditions (MeSH)

D003920 - Diabetes Mellitus, D006973 - Hypertension, D000740 - Anemia, D016030 - Kidney Transplantation, D007676 - Kidney Failure, Chronic

Keywords

chronic kidney disease, Kidney Dialysis, glomerular filtration rate (GFR)

Methodology

Number of Source Documents
244
Literature Search Start Date
December 1, 2013
Literature Search End Date
September 27, 2018