CKD Pathway - Medical Management

No Diabetes
Diabetes

Prescribing Information

Prescribe an ACEi or ARB if ACR > 30 mg/mmol and no contraindications.

Dosage

Titrate to maximum tolerated dose.

Contra-
indications

Pregnancy
Women with childbearing potential should only use an ACEi or ARB if there is reliable contraception.

General
Information

Check potassium and eGFR within 2 weeks of starting or dose changes.
Combined therapy of ACEi and ARB not recommended.
ACEi or ARBs can cause a reversible reduction in eGFR when treatment is initiated (approximately 25%):
- » If the reduction in eGFR exceeds 25% below the baseline value, stop ACEi or ARB.
- » If the reduction in eGFR is 5 to 25%, re-check in 2-3 weeks to exclude further deterioration.
Increases in serum potassium of up to 0.5mmol/L can be expected with ACEi or ARB use.
ACEi or ARBs can safely be prescribed at all stages of CKD and should not be deliberately avoided with reduced eGFR.
Assess for baseline cough, if bothersome cough with ACEi consider switching to ARB.
Check the potassium and eGFR in times of acute illness, particularly influenza and diarrheal illness.

Prescribing Information

Age > 50: Prescribe statin unless contraindicated.
Age 18 – 49 : Prescribe statin if no contraindications and if any one of the following:

Known coronary disease (myocardial infarction or coronary revascularization).
Prior ischemic stroke.
Estimated 10-year incidence of coronary death or non-fatal MI >10%. (Calculate your Patient's Framingham Risk Score)

Dosage

Statin	eGFR < 60 mL/min/1.73m²
Lovastatin	Not studied
Fluvastatin	80 mg
Atorvastatin	20 mg
Rosuvastatin	10 mg
Simvastatin/Ezetmibe	20 mg/10 mg
Pravastatin	40 mg
Simvastatin	40 mg

Recommended doses (mg/d) of statins in adults with CKD

Contra-
indications

Active liver disease, high alcohol consumption or pregnancy.
Women with childbearing potential should only use statin if there is reliable contraception.

General
Information

No follow-up monitoring of lipid levels required unless the result will change course of therapy.
Measure ALT prior to starting a statin. Follow-up monitoring not required as abnormalities are low in patients with normal baseline ALT.
CK not required at baseline or during follow-up unless patient develops symptoms suggestive of myopathy.

Prescribing Information

Low dose ASA (81mg) may be used for secondary prevention in patients with established vascular disease:

Acute coronary syndrome
Prior MI or coronary revascularization
Prior stroke or TIA
PVD (high risk patients with low bleeding risk).

Dosage

81 mg

Contra-
indications

History of ASA induced GI bleed.

General
Information

Low dose ASA for secondary prevention only.

Prescribing Information

For persons with CKD and no diabetes.

Dosage

SGLT2i	eGFR < 30 mL/min/1.73m²	eGFR ≥ 30 and ≤ 60 mL/min 1.73m²
Dapagliflozin	Do not initiate if GFR < 25; Consult Nephrology. If already prescribed, may continue 10mg PO daily. Discontinue once on dialysis.	Approved for use in eGFR ≥ 25. Dosage for outcome reduction is 10 mg PO daily (non diabetic CKD and/or HFrEF).
Canagliflozin	Not indicated for persons with CKD and without Diabetes.
Empagliflozin	Not indicated for persons with CKD and without Diabetes.

Contra-
indications

Except where noted above SGLT2is are contraindicated for eGFR < 30 mL/min/1.73 m².
Patients hypersensitive to medications in this class.
Patients who are currently volume depleted.
Not recommended in pregnancy or breast feeding.
Relative contraindication in pts who have acute gangrenous ulcer or recent amputation (hold for 6 months from resolution).

General
Information

Health Canada (August 2021) expanded the indications for Dapagliflozin to reduce the risk of sustained estimated glomerular filtration rate (eGFR) decline, end-stage kidney disease (ESKD), and cardiovascular (CV) and renal death in adults with chronic kidney disease (CKD) in patients with or without Type 2 Diabetes.

Prescribing Information

Prescribe an ACEi or ARB unless contraindicated.

Dosage

Titrate to maximum tolerated dose.

Contra-
indications

Pregnancy
Women with childbearing potential should only use an ACEi or ARB if there is reliable contraception.

General
Information

Check potassium and eGFR within 2 weeks of starting or dose changes.
Combined therapy of ACEi and ARB not recommended.
ACEi or ARBs can cause a reversible reduction in eGFR when treatment is initiated (approximately 25%):
- » If the reduction in eGFR exceeds 25% below the baseline value, stop ACEi or ARB.
- » If the reduction in eGFR is 5 to 25%, re-check in 2-3 weeks to exclude further deterioration.
Increases in serum potassium of up to 0.5mmol/L can be expected with ACEi or ARB use.
ACEi or ARBs can safely be prescribed at all stages of CKD and should not be deliberately avoided with reduced eGFR.
Assess for baseline cough, if bothersome cough with ACEi consider switching to ARB.
Check the potassium and eGFR in times of acute illness, particularly influenza and diarrheal illness.

Prescribing Information

Prescribe statin unless contraindicated.

Dosage

Statin	eGFR < 60 mL/min/1.73m²
Lovastatin	Not studied
Fluvastatin	80 mg
Atorvastatin	20 mg
Rosuvastatin	10 mg
Simvastatin/Ezetmibe	20 mg/10 mg
Pravastatin	40 mg
Simvastatin	40 mg

Recommended doses (mg/d) of statins in adults with CKD

Contra-
indications

Active liver disease, high alcohol consumption or pregnancy.
Women with childbearing potential should only use statin if there is reliable contraception.

General
Information

No follow-up monitoring of lipid levels required unless the result will change course of therapy.
Measure ALT prior to starting a statin. Follow-up monitoring not required as abnormalities are low in patients with normal baseline ALT.
CK not required at baseline or during follow-up unless patient develops symptoms suggestive of myopathy.

Prescribing Information

Low dose ASA (81mg) may be used for secondary prevention in patients with established vascular disease:

Acute coronary syndrome
Prior MI or coronary revascularization
Prior stroke or TIA
PVD (high risk patients with low bleeding risk).

Dosage

81 mg

Contra-
indications

History of ASA induced GI bleed.

General
Information

Low dose ASA for secondary prevention only.

Prescribing Information

For persons with DKD.

Dosage

SGLT2i	eGFR < 30 mL/min/1.73m²	eGFR ≥ 30 mL/min 1.73m²
Canagliflozin	Do not initiate; Consult Nephrology. If already prescribed, may continue 100mg PO daily. Discontinue once on dialysis.	Dosage for outcome reduction start 100 mg PO daily; may increase up to 300mg PO daily for additional A1C control when GFR > 60.
Dapagliflozin	Do not initiate if GFR < 25; Consult Nephrology. If already prescribed, may continue 10mg PO daily. Discontinue once on dialysis.	Approved for use in eGFR ≥ 25. Dosage for outcome reduction is 10 mg PO daily (DKD and/or HFrEF).
Empagliflozin	Not indicated for DKD; use alternative agent if initiating therapy but may continue this agent in patient who are already initiated. May consider: HFrEF Treatment at GFR > 20. Discontinue once on dialysis.	10 mg OD for Organ protection. 25 mg OD for A1C control.

Contra-
indications

Except where noted above SGLT2is are contraindicated for eGFR < 30 mL/min/1.73 m².
Patients hypersensitive to medications in this class.
Patients with Type 1 Diabetes.
Patients with history of Diabetic Ketoacidosis.
Patients who are currently volume depleted.
Not recommended in pregnancy or breast feeding.
Relative contraindication in pts who have acute gangrenous ulcer or recent amputation (hold for 6 months from resolution).

General
Information

Health Canada (2020) approved Canagliflozin for the prevention of progression of diabetic nephropathy in 2020.
Health Canada (August 2021) expanded the indications for Dapagliflozin to reduce the risk of sustained estimated glomerular filtration rate (eGFR) decline, end-stage kidney disease (ESKD), and cardiovascular (CV) and renal death in adults with chronic kidney disease (CKD) in patients with or without Type 2 Diabetes.

Other Considerations