Medical Management

Lifestyle Management

  • Exercise 150 minutes per week, or to a level compatible with cardiovascular and physical tolerance
  • Achieve an optimal BMI (18.5 – 25)
  • Do not use tobacco products
  • Adequate fluid intake: Fluid restriction is not necessary for most patients.
  • Low sodium diet (2000 mg/day)
Download Sodium Food Handout (PDF)
Download Potassium Food Handout (PDF)
Download Phosphorus Food Handout (PDF)
Targets
  • Adults with high Blood Pressure and CKD should be treated to a target systolic blood pressure of <120mmHg if tolerated. Consider less intensive BP-lowering in people with frailty, high risk of falls or fracture, limited life expectancy, or with symptomatic postural hypotension.
  • A1C target for patients with diabetes: < 7% eGFR info
Download Patient Tips for Managing CKD (PDF)


Drug Therapy
Prescribing Information
Prescribe an ACEi or ARB if ACR > 30 mg/mmol and eGFR > 15 mL/min/1.73m2 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 2-4 weeks of starting or dose changes.
  • Combined therapy of ACEi, ARB, or direct renin inhibitor not recommended.
  • ACEi or ARBs can cause a reversible reduction in eGFR when treatment is initiated (up to 30%):
    • »  If the reduction in eGFR exceeds 30% below the baseline value, consider reducing the dose or stopping 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 categories 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:
Dosage
Statin eGFR < 60 mL/min/1.73m2
Fluvastatin 80 mg
Atorvastatin 20 mg
Rosuvastatin 10 mg
Simvastatin/Ezetimibe 20 mg/10 mg
Pravastatin 40 mg
Simvastatin 40 mg

Recommended starting 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. Tooltip
  • 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, SGLT2i should be prioritized in patients with ACR > 20 mg/mmol who are already prescribed ACEi/ARB or for patients who are intolerant of ACEi/ARB.
In patients with GFR 20 – 45, consideration could be given to SGLT2i prescribing in the absence of proteinuria.
Dosage
SGLT2i eGFR < 20 eGFR 20-45 eGFR ≥ 45
Canagliflozin Do not initiate. Not indicated for persons with CKD and without Diabetes.
Dapagliflozin Do not initiate.

If already prescribed, may continue 10mg PO daily.

Discontinue once on dialysis. 		At any ACR threshold.

Dosage for outcome reduction is 10 mg PO daily. 		If ACR > 20mg/mmol.

Dosage for outcome reduction is 10 mg PO daily.
Empagliflozin Do not initiate.

If already prescribed, may continue.

Discontinue once on dialysis. 		At any ACR threshold.

10 mg PO daily for Organ protection.

Up to 25 mg PO daily for A1C control. 		If ACR > 20mg/mmol.

10 mg PO daily for Organ protection.

Up to 25 mg PO daily for A1C control.
Consider consulting nephrology if outside of these recommendations.
Contra-indications
  • 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.
  • Health Canada (January 2024) expanded the indications for Empagliflozin to reduce the risk of sustained eGFR decline, ESKD and cardiovascular 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 if ACR > 3 mg/mmol.
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 2-4 weeks of starting or dose changes.
  • Combined therapy of ACEi, ARB, or direct renin inhibitor not recommended.
  • ACEi or ARBs can cause a reversible reduction in eGFR when treatment is initiated (up to 30%):
    • »  If the reduction in eGFR exceeds 30% 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 categories 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
Fluvastatin 80 mg
Atorvastatin 20 mg
Rosuvastatin 10 mg
Simvastatin/Ezetimibe 20 mg/10 mg
Pravastatin 40 mg
Simvastatin 40 mg

Recommended starting 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. Tooltip
  • 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. For additional information, consider reviewing the Chronic Kidney Disease in Diabetes Mellitus 2 Pathway

We recommend treating patients with type 2 diabetes (T2D), CKD, and an eGFR ≥ 20 ml/min/1.73m2 with an SGLT2i.
Dosage
SGLT2i eGFR < 20 eGFR 20-45 eGFR ≥ 45
Canagliflozin Do not initiate.

If already prescribed, may continue.

Discontinue once on dialysis. 		At any ACR threshold.

Dosage for outcome reduction start 100 mg PO daily. 		At any ACR threshold if GFR < 60, and ACR > 3mg/mmol or PCR > 15 mg/mmol if GFR is above 60.

Dosage for outcome reduction start 100 mg PO daily; may increase up to 300mg PO daily for additional A1C control when eGFR > 60 mL/min/1.73m2.
Dapagliflozin Do not initiate.

If already prescribed, may continue.

Discontinue once on dialysis. 		At any ACR threshold.

10 mg PO daily for Organ protection. 		At any ACR threshold if GFR < 60, and ACR > 3 mg/mmol or PCR > 15 mg/mmol if GFR is above 60.

10 mg PO daily for Organ protection.
Empagliflozin Do not initiate.

If already prescribed, may continue.

Discontinue once on dialysis. 		At any ACR threshold.

10 mg PO daily for Organ protection.

Up to 25 mg PO daily for A1C control. 		At any ACR threshold if GFR < 60, and ACR > 3 mg/mmol or PCR>15 mg/mmol if GFR is above 60.

10 mg PO daily for Organ protection.

Up to 25 mg PO daily for A1C control.
Consider consulting nephrology if outside of these recommendations.
Contra-indications
  • 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.
  • Health Canada (January 2024) expanded the indications for Empagliflozin to reduce the risk of sustained eGFR decline, ESKD, and cardiovascular and renal death in adults with chronic kidney disease (CKD) in patients with or without Type 2 Diabetes
Prescribing Information
In people with type 2 diabetes and CKD who are already receiving or are not able to use metformin and SGLT2i, and have not reached glycemic targets, a long-acting GLP1-RA is recommended.
Dosage
Semaglutide 0.25mg SC q7days as the initial starting dose x 4 weeks, with escalation to 0.5ug q7days. For additional glycemic control may increase by 0.5mg every 4 weeks up to 2mg/week.
Contra-indications
  • Type 1 diabetes
  • History of pancreatitis
  • Multiple endocrine neoplasia type 2
General Information
  • In many jurisdictions, special authorization is required for prescription.
Prescribing Information
Non-steroidal mineralocorticoid receptor antagonists (nsMRAs) have been shown to have cardiovascular and kidney benefit for adults with type 2 diabetes and CKD. A nsMRA is recommended for this group with eGFR > 25 mL/min/1.73m2, normal serum potassium, and a urine ACR > 3 mg/mmol if already on maximal RAS inhibition.
Dosage
MRA eGFR < 25 eGFR 25-60 eGFR ≥ 60
Finerenone Do not initiate.

If already prescribed, may continue until eGFR reaches 15 or dialysis. 		Stating dose 10mg PO daily. Starting dose 20mg PO daily.
If finerenone is not available, consideration of a MRA such as spironolactone is recommended if patient has heart failure, hyperaldosteronism, or refractory hypertension.

All of these options can be added to ACEi/ARB and SGLT2i for treatment of people with CKD and diabetes.
Contra-indications
  • Current use of dialysis
  • Recurrent hyperkalemia, particularly if K > 5.0mmol/L
  • Current use of another MRA
General Information
  • Check potassium and eGFR within 2-4 weeks of starting or dose changes.
  • Increases in serum potassium of up to 0.5 mmol/L can be expected.
  • Check the potassium and eGFR in times of acute illness, particularly influenza and diarrheal illness.
  • In many jurisdictions, special authorization may be needed for prescription.
Other Considerations
Download Management of elevated serum potassium (PDF)
Download Drugs that may raise potassium (PDF)
Common drugs
that may have nephrotoxic effects
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Common drugs
that may require renal dose adjustments
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Sick day
Medication List
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