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/Ezetimibe 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 Indicated by Health Canada to prevent progression of kidney disease in patients with, and without, Type 2 Diabetes.

Do not initiate if eGFR < 20; Consult Nephrology If already prescribed, may continue 10mg PO daily.

May continue on dialysis, but there is limited data. 		10 mg PO daily for Organ protection.

Up to 25 mg PO daily 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 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, end-stage kidney disease 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 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/Ezetimibe 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 if GFR < 30; 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 Indicated by Health Canada to prevent progression of kidney disease in patients with, and without, Type 2 Diabetes.

Do not initiate if eGFR < 20; Consult Nephrology

If already prescribed, may continue 10mg PO daily.

May continue on dialysis, but there is limited data. 		10 mg PO daily for organ protection.

May increase up to 25 mg PO daily for A1C control when GFR ≥ 30.
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
  • Dapagliflozin and Empagliflozin are indicated by Health Canada to prevent progression of kidney disease in patients with, and without, Type 2 Diabetes.
  • Canagliflozin is indicated by Health Canada to prevent of progression of kidney disease in patients with 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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