Medical Management

Lifestyle Management

  • Exercise 30 minutes, 5 times per week
  • Achieve a healthy BMI (18.5 – 25)
  • Smoking cessation
  • Adequate fluid intake: Fluid restriction is not necessary for most patients.
  • Healthy diet: low sodium diet (2000 mg/day)
Download Sodium Food Handout (PDF)
Download Potassium Food Handout (PDF)
Download Phosphorus Food Handout (PDF)
Targets
  • Blood pressure targets:

    Diabetic: <130/80 mmHg

    Non diabetic: <140/90 mmHg

  • 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 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:
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. 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 > 3 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 < 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. 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
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
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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