Slow Progression and Reduce Complications

Although CKD is generally progressive and irreversible, there are steps providers and patients can take to slow progression, enabling patients to live longer without complications or the need for renal replacement therapy. The National Institute of Diabetes and Digestive and Kidney Disease-funded Chronic Renal Insufficiency Cohort (CRIC) Study is examining risk factors for progression of CKD and the occurrence of cardiovascular disease (CVD) among patients with CKD. Insights from CRIC will inform future treatment trials and may result in revisions to treatment guidelines for risk factor reduction.

Treatment strategies to slow progression and reduce cardiovascular risk are similar. They include:

• nutritional interventions
• lifestyle interventions
• medical management to control blood pressure and blood glucose, and reduce albuminuria

Even with these interventions, kidney disease will progress in some patients. In this case, monitoring for the associated complications and comorbidities is indicated. These may include:

• cardiovascular disease and dyslipidemia
• anemia due to impaired erythropoiesis and low iron stores
• malnutrition
• mineral and bone disorders
• depression and decreased functional status

Nutritional Interventions

The purpose of diet therapy in CKD is two-fold: to delay progression and to prevent and treat complications, including malnutrition. The first steps in diet therapy are to:

• Limit dietary sodium to 1,500 mg/day to help control blood pressure.
  • Salt substitutes are generally rich in potassium and may need to be avoided with use of medications that block the renin-angiotensin-aldosterone system.
• Provide adequate, not excessive protein intake which may help reduce albuminuria and slow progression
  • Adequate protein intake is 0.8 g/kg body weight/day*

Choose foods that are heart healthy. As CKD progresses, the next steps may include limiting dietary phosphorus and potassium. If dietary phosphorus restriction is indicated, avoiding food with phosphorus food additives may be an appropriate first step. Adequate calories across the continuum are imperative to maintain nutritional status.

It is vital to engage a dietitian knowledgeable in CKD diet and nutrition to assess and initiate individualized medical nutrition therapy (MNT) for patients with CKD. If dietary consultation is delayed or unavailable, other providers may find NKDEP’s Eating Right for Kidney Health helpful for guiding patients on the diet. To find a dietitian near you, search the Academy of Nutrition and Dietetics directory.

*Evidence suggests that further lowering to 0.6 g protein/kg/day in patients without diabetes may be beneficial, but adherence is difficult. Some patients may be able to achieve this level with intensive counseling.

Lifestyle Interventions

Encourage health-promoting behaviors such as smoking cessation and physical activity. Cigarette smoking is associated with abnormal urine albumin and progression of CKD. Smoking also contributes to death from stroke and heart attack in people with CKD. Overall, step-down nicotine replacement therapy is generally safe, but the patient must be monitored for side effects, which may include worsening of existing hypertension and contact allergy or sensitization.

Although people with CKD tend to be less active, the goals for physical activity are the same as in the general population, at least 20 to 30 minutes every day. To improve or prevent deconditioning, both aerobic and strength training should be encouraged. Physical activity may help prevent cardiovascular disease, improve glucose control in those with diabetes, and maintain muscle mass.

Evidence suggests that providing self-management education to patients with chronic disease results in reduced health service utilization and improved health behaviors and health status beyond that achieved by usual care.

Medical Management

Key interventions include blood pressure control, blockade of the renin-angiotensin aldosterone system (RAAS) with ACE inhibitors or ARBs, and blood glucose control in those with diabetes. The use of ACE inhibitors and ARBs has been found to slow progression of CKD and is considered first-line treatment in patients with albuminuria.

Strategies for slowing progression:

• Improved blood pressure control. Controlling blood pressure is probably the most effective intervention to slow progressive kidney disease.
• ACE inhibitors/ARBs for blood pressure control and to reduce albuminuria. In addition to treating hypertension, these drugs may also be beneficial in glomerular (albuminuric) kidney disease when hypertension is not present.
• Blood glucose control for patients with diabetes. Optimal control of diabetes prior to the development of kidney disease may prevent the development of kidney disease. Once kidney disease is present, tight control may not have an effect on kidney disease progression, compared to less tight control.

Blood Pressure Control

High blood pressure is both a cause and 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 less than 130/80 mmHg is based on observational data. Certain individuals may experience adverse events at this level compared to a target blood pressure < 140/90 mmHg.

The SPRINT trial, currently underway, will examine a range of blood pressure goals in patients with CKD.

Monitor Blood Pressure

Routine monitoring of blood pressure is recommended for all patients with CKD. The following techniques are recommended:

• Patient should refrain from smoking or ingesting caffeine 30 minutes prior to measurement.
• Patient should sit in a chair with back supported, arms bared, and supported at heart level.
• Patient should be allowed to rest for 5 minutes in the chair prior to measurement.
• Use appropriate-sized cuff.

Treat High Blood Pressure

Antihypertensive medications and lifestyle modifications are the cornerstones for treating high blood pressure.

ACE inhibitors and ARBs have been shown to slow the progression of CKD, particularly in patients with albuminuria. These medications lower glomerular capillary blood pressure as well as systemic blood pressure. These classes of drugs may also be considered in glomerular (albuminuric) kidney disease when hypertension is not present. Monitor for hyperkalemia when prescribing these medications.

If the patient is not meeting the blood pressure goal, review

• adequacy of dietary salt restriction
• adequacy of diuretic regimen
• adherence to medication regimen

Reduce Albuminuria

Elevated urine albumin is associated with increased risk of renal events and lowering urine albumin may decrease the risk of progression.. ACE inhibitors and ARBs have been shown to slow the progression of CKD, which may be reflected in decreased albuminuria. These medications lower glomerular capillary blood pressure as well as systemic blood pressure. They may also be considered in glomerular (albuminuric) kidney disease when hypertension is not present. Sodium restriction may enhance the effectiveness of these medications.

• Monitor for hyperkalemia when using either ACE or ARBs. Small, nonprogressive increases in serum creatinine after initiating these agents may reflect hemodynamic changes rather than progression of kidney disease.

Weight loss, lowering dietary sodium and restriction of excessive dietary protein intake may reduce albuminuria. Refer to a registered dietitian knowledgeable in the CKD diet, as needed.

Blood Glucose Control

Achieving and maintaining optimal glucose control may reduce the risk of developing albuminuria. Intensive glycemic control lessens progression of albuminuria in type 1 diabetes; benefits in type 2 are less clear. Current guidelines for diabetes recommend achieving a goal of the A1C of less than 7 percent. However, recent evidence emphasizes the importance of individualizing therapeutic goals.

• Consider less stringent glycemic control for the elderly and for patients with a history of severe hypoglycemia and/or multiple comorbid conditions.
• Consider more intensive glycemic control in younger patients without a history of severe hypoglycemia or comorbidities in whom prevention of microvascular complications is a primary objective.
• An unexplained improvement in glucose control or increased frequency and/or severity of hypoglycemia may reflect progression of CKD due to the reduced renal metabolism of insulin and impaired gluconeogenesis by the kidneys.