Prevention of Kidney Disease Progression

1. See Also
   1. Chronic Kidney Disease
   2. Intravenous Contrast Related Acute Renal Failure
   3. Drug Dosing in Chronic Kidney Disease
   4. Nephrotoxic Drugs
   5. Renal Osteodystrophy
2. Management: Nephrology consultation indications
   1. Single GFR in past 12 months < 30 mL/min
   2. Single GFR < 60 mL/min AND Blood Pressure > 130/80 (consistently) despite antihypertensive medications
   3. Single GFR < 60 mL/min AND Hemoglobin < 10 g/dL
   4. Single GFR < 60 mL/min AND Hyperparathyroidism (PTH > 72 pg/mL) despite correcting for any Vitamin D Deficiency
   5. Proteinuria > 1 gram/24 hours
   6. Unexplained Hematuria
   7. Unexplained decline in GFR > 15 mL/min between two readings
3. Management: Fluids, electrolytes and nutrition
   1. Careful fluid balance (avoid Fluid Overload as well as dehydration)
   2. Protein restriction (controversial)
      1. Low Protein diet
         1. Serum Creatinine 2-4 (GFR 25-55): 0.8 mg/kg/day
         2. Serum Creatinine >4 (GFR <25): 0.6 mg/kg/day
      2. Institute when Serum Creatinine >= 1.7
      3. Appears to significantly benefit only Diabetics
      4. Contraindications to protein restriction
         1. Hemodialysis
         2. Elderly
         3. Malnutrition
         4. Nephrotic Syndrome (due to high protein losses)
   3. Hyperkalemia
      1. Limit Dietary Potassium intake to 70 meq/day
   4. Metabolic Acidosis
      1. Treat if serum bicarbonate <20
   5. Unintentional Weight Loss
      1. Minimum intake: 35 Kcal/kg/day
   6. Hyperphosphatemia
      1. See Renal Osteodystrophy
      2. Causes Osteitis fibrosa cystica (poor bone strength)
      3. Results from Hyperparathyroidism
      4. Management
         1. Restrict dietary phosphate (limit to 1200 mg/day)
            1. Avoid soda
            2. Avoid nuts, peas or beans
            3. Avoid dairy products
         2. Medications
            1. See Calcium and Phophorus Metabolism in Chronic Kidney Disease
            2. Calcium Supplementation (maximum 1.2 to 2.0 grams daily)
            3. Phosphate-binding
               1. Calcium Carbonate or acetate
               2. Sevelamer hydrochloride or carbonate
            4. Vitamin D Supplementation (critical!)
            5. Correct acidosis
4. Management: Comorbid conditions
   1. Avoid Nephrotoxic Drugs
   2. Maximize glycemic control in Diabetes Mellitus
   3. Observe closely for Coronary Artery Disease
      1. High Incidence of comorbidity
      2. Most ESRD patients die of CAD before Dialysis
   4. Control Hyperlipidemia (Statin drugs are preferred)
      1. Goal LDL Cholesterol <100 mg/dl
      2. Goal Triglycerides <200 mg/dl
   5. Avoid additional Kidney injury
      1. Early recognition and treatment of UTI
      2. Avoid volume depletion
      3. Avoid Nephrotoxic Drugs
      4. Tobacco Cessation
      5. Limit radiologic Contrast Material to low density
   6. Osteoporosis
      1. Control calcium and phosphorus
      2. Control Parathyroid Hormone
      3. Use Bisphosphonates only with caution
         1. Consider nephrology consultation
         2. Do not use for GFR <30-40 ml/min
         3. Only use for strong indications
            1. Fractures or bone loss
            2. High bone turnover by bone biopsy
            3. Controlled PTH, Calcium and phosphorus
5. Management: Evaluate and manage common complications
   1. Anemia (Hemoglobin <11 grams per dl)
      1. Iron supplement indicated for Ferritin <10 ng/ml
      2. Erythropoetin or Aranesp indications
         1. Anemia dependent Angina
         2. Hemoglobin <10 grams/dl or Hematocrit <30-32
            1. Use goal >9 grams/dl in comorbid cancer
6. Management: Hypertension and Proteinuria
   1. Most important preventive measure
   2. Goals of therapy
      1. Decrease Blood Pressure below 120/80
      2. Decrease Proteinuria by 50%
   3. Control Hypertension and Proteinuria with ACE Inhibitor
      1. ACE Inhibitor should be first antihypertensive used
         1. Efficacious in Diabetic Nephropathy
         2. Efficacious in non-diabetic renal disease
         3. Jafar (2001) Ann Intern Med 135:73-87
      2. Indication
         1. Proteinuria on Urinalysis (1+ Protein on Urinalysis or >1 gram per day)
         2. Microalbuminuria in Diabetes Mellitus
         3. Hypertension (Blood Pressure >130/80 mmHg)
      3. Observe for Hyperkalemia
         1. Avoid with potassium sparing Diuretic
         2. Avoid with Potassium Supplementation
      4. Management with adverse effects
         1. Orthostasis: Maximize clear fluid intake
   4. Adjunctive antihypertensive agents
      1. Step 1: ACE Inhibitor or Angiotensin Receptor Blocker
         1. See above
      2. Step 2: Non-Dihydropyridine Calcium Channel Blocker
         1. Diltiazem or
         2. Verapamil
      3. Step 3: Hydrochlorothiazide (or other Thiazide Diuretic)
         1. Use Furosemide (or other Loop Diuretic) instead if Creatinine Clearance <30 ml/min
      4. Step 4: Beta Blocker
         1. Use with caution due to possible adverse outcomes (including third degree AV Block)
7. References
   1. (2002) Am J Kidney Dis 39:S1
   2. Snively (2004) Am Fam Physician 70:1921-30
   3. Stigant (2003) CMAJ 168:1553-60