Management of progression

Prevention of CKD progression

The management of progression of CKD is aimed at addressing a multiplicity of factors known to be associated with progression. NephroCare supports and encourages utilising a common strategy adopting the best medical practices included in the KDIGO Guideline for the Evaluation and Management of CKD. Based on this, NephroCare recommends for example general lifestyle measures which improve cardiovascular health, blood pressure control, interruption of the renin-angiotensin-aldosterone system (RAAS) and medical intervention as described below.

Blood Pressure (BP)

Controlling blood pressure is probably the most effective intervention to slow progressive kidney disease. High blood pressure is both a cause and a complication of CKD. Uncontrolled high blood pressure can accelerate the loss of GFR. Blood pressure control usually requires a combination of antihypertensive medications and lifestyle modifications.

Blood pressure goals are unclear in CKD. The recommendation that all people with kidney disease should achieve a blood pressure <140/90 mmHg is based on observational data. Patients with proteinuria have a stricter target of < 130/80. Certain individuals may experience adverse events at this level compared to a target blood pressure <140/90 mmHg.2

CKD and risk of Acute Kidney Insufficiency (AKI)

In people with CKD, the recommendations detailed in the KDIGO AKI Guideline should be followed for management of those at risk of AKI during intercurrent illness, or when undergoing investigation and procedures that are likely to increase the risk of AKI.1

Protein intake

The nephrological community suggests lowering protein intake to 0.8 g/kg/day in adults with diabetes or without diabetes and GFR <30 ml/min/1.73 m2 (GFR categories G4-G5), with appropriate education.

It is suggested to avoid high protein intake (>1.3 g/kg/day) in adults with CKD at risk of progression.1

Glycemic control

Reducing glycosylated hemoglobin (HbA1c) to near or less than 7% in patients with diabetes is associated with reduced microvascular complications.It is recommended a target hemoglobin A1c of ~ 7.0% (53 mmol/mol).

Salt intake

The nephrological community recommends lowering salt intake to <90 mmol (<2 g) per day of sodium (corresponding to 5 g of sodium chloride) in adults, unless contraindicated.1

Hyperuricemia

There is insufficient evidence to support or refute the use of agents to lower serum uric acid concentrations in people with CKD and either symptomatic or asymptomatic hyperuricemia in order to delay progression of CKD.1

Lifestyle

The nephrological community recommends that people with CKD be encouraged to undertake physical activity compatible with cardiovascular health and tolerance (aiming for at least 30 minutes 5 times per week), achieve a healthy weight (BMI 20 to 25, according to country specific demographics), and stop smoking.1

Additional dietary advice

The nephrological community recommends that individuals with CKD receive expert dietary advice and information in the context of an education programme, tailored to the severity of CKD and the need to intervene on salt, phosphate, potassium, and protein intake where indicated.1

Medical intervention

It is recommended that prescribers should take GFR into account when drug dosing.1

Where precision is required for dosing (due to narrow therapeutic or toxic range) and/or estimates may be unreliable (e.g. due to low muscle mass), the nephrological community recommends methods based upon cystatin C or direct measurement of GFR.1

Temporary discontinuation of potentially nephrotoxic and renally excreted drugs is recommended in people with a GFR <60 ml/min/1.73 m2 (GFR categories G3a-G5) who have serious intercurrent illness that increases the risk of AKI. These agents include, but are not limited to: RAAS blockers (including ACE-inhibitors, ARBs, aldosterone inhibitors, direct renin inhibitors), diuretics, NSAIDs, metformin, lithium, and digoxin.1

It is recommended that metformin be continued in people with GFR >45 ml/min/1.73 m2 (GFR categories G1-G3a); its use should be reviewed in those with GFR 30–44 ml/min/1.73 m2 (GFR category G3b); and it should be discontinued in people with GFR<30 ml/min/1.73 m2 (GFR categories G4-G5).1

It is also recommended that all people taking potentially nephrotoxic agents such as lithium and calcineurin inhibitors should have their GFR, electrolytes and drug levels monitored regularly.1

It is recommended that adults with CKD seek medical or pharmacist advice before using over-the-counter medicines or nutritional protein supplements.1

It is recommended not to use herbal remedies in people with CKD.1 People with CKD should not be denied therapies for other conditions such as cancer but there should be appropriate dose adjustment of cytotoxic drugs according to knowledge of GFR.1

Conservative management

Conservative management should be an option in people who choose not to pursue RRT. All CKD programs and care providers should be able to deliver advance care planning for people with a recognised need for end-of-life care, including those people undergoing conservative kidney care. Coordinated end-of-life care should be available to people and families through either primary care or specialist care as local circumstances dictate.1

The comprehensive conservative management programme should include protocols for symptom and pain management, psychological care, spiritual care, and culturally sensitive care for the dying patient and their family (whether at home, in a hospice, or a hospital setting), followed by the provision of culturally appropriate bereavement support.1