Prevention of Kidney Disease Progression

Aka: Prevention of Kidney Disease Progression, Chronic Kidney Disease Prevention

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II. 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

III. Management: Fluids, Electrolytes and nutrition

  1. See Chronic Kidney Disease
  2. Careful fluid balance (avoid Fluid Overload as well as Dehydration)
  3. Protein restriction (controversial)
    1. Low Protein diet
      1. Serum Creatinine 2-4 (GFR 25-55): 0.8 g/kg/day
      2. Serum Creatinine >4 (GFR <25): 0.6 g/kg/day
    2. Institute when Serum Creatinine >= 1.7
    3. Appears to significantly benefit only patients with Diabetes Mellitus
    4. Contraindications to Protein restriction
      1. Hemodialysis
      2. Elderly
      3. Malnutrition
      4. Nephrotic Syndrome (due to high Protein losses)
  4. Hyperkalemia
    1. Limit Dietary Potassium intake to 70 meq/day
  5. Metabolic Acidosis
    1. Treat if serum bicarbonate <20
  6. Unintentional Weight Loss
    1. Minimum intake: 35 Kcal/kg/day
  7. 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

IV. Management: Comorbid conditions

  1. Diabetes Mellitus
    1. See Diabetic Nephropathy
    2. Maximize glycemic control in Diabetes Mellitus
      1. Hemoglobin A1C <7% best reduces Diabetic Nephropathy risk
      2. Precaution: ACCORD Study found higher overall mortality with intensive glycemic control in Type II Diabetes
        1. Gerstein (2008) N Engl J Med 358(24): 2545-59 [PubMed]
  2. Coronary Artery Disease
    1. High Incidence of comorbidity
    2. Most ESRD patients die of Coronary Artery Disease before Dialysis
    3. CAD primary prevention in Chronic Kidney Disease for those WITHOUT Coronary Artery Disease
      1. Antiplatelet Therapy (e.g. Aspirin) reduces the risk of MI (NNT 125) but increases the risk of major bleed (NNH 100)
      2. Natale (2022) Cochrane Database Syst Rev (2): CD008834 [PubMed]
  3. Hyperlipidemia
    1. Statin drugs are preferred
    2. Goal LDL Cholesterol <100 mg/dl
    3. Goal Triglycerides <200 mg/dl
    4. Lipid lowering therapy beyond age 80 does not appear to alter all-cause mortality
      1. Petersen (2010) Age Ageing 39(6): 674-80 [PubMed]
  4. Avoid additional Kidney injury
    1. Early recognition and treatment of UTI
    2. Tobacco Cessation
    3. Avoid Rhabdomyolysis Causes
  5. Maintain hemodynamic stability in Acute Renal Failure
    1. Avoid volume depletion
    2. Maintain mean arterial pressure >65 mmHg
      1. Vasopressors may be required
      2. Avoid renal dose Dopamine due toworse outcomes
  6. Manage Nephrotoxicity Risks
    1. Avoid Nephrotoxic Drugs
    2. Measure drug levels of nephrotoxic medications
    3. Limit radiologic Contrast Material to low density
      1. See Intravenous Contrast Related Acute Renal Failure
      2. See Gadolinium-Associated Nephrogenic Systemic Fibrosis (Nephrogenic Fibrosing Dermopathy)
      3. See Risk Score for Prediction of Contrast-Induced Nephropathy After Percutaneous Coronary Intervention
      4. Prefer lowest volume of lowest osmolar Contrast Material
      5. Optimize hydration status (e.g. Isotonic Saline) prior to Contrast Material and consider N-Acetylcysteine
  7. Chemotherapy with risk of Tumor Lysis Syndrome (prevent Uric Acid nephropathy)
    1. Pre-hydrate prior to Chemotherapy
    2. Consider Allopurinol prior to Chemotherapy
  8. Hepatic failure (Cirrhosis)
    1. Early recognition and treatment of bleeding, Ascites and Spontaneous Bacterial Peritonitis
    2. Replace albumin as needed

V. 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 decline requires transfusion
      3. Hemoglobin <10 grams/dl or Hematocrit <30-32
        1. Use goal >9 grams/dl in comorbid cancer
        2. Avoid increasing Hemoglobin >11 g/dl (higher morbidity and mortality)
    3. References
      1. (2007) Am J Kidney Dis 50(3): 471-530 [PubMed]
      2. FDA EPO agent recommendations
        1. http://www.fda.gov/Drugs/DrugSafety/ucm259639.htm
  2. 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

VI. Management: Hypertension and Proteinuria

  1. Most important preventive measure
  2. Goals of therapy
    1. Decrease Proteinuria by 50%
    2. Decrease Blood Pressure below 130/80
      1. Goal BP in Chronic Kidney Disease is controversial
      2. Arguedas (2009) Cochrane Database Syst Rev CD004349
      3. (2004) Am J Kidney Dis 43(5 suppl 1): S1-S290 [PubMed]
  3. General Measures
    1. Limit Dietary Sodium intake (<2300 mg/day)
      1. Lowers Blood Pressure and decreases albuminuria
      2. McMahon (2021) Cochrane Database Syst Rev (6):CD010070 [PubMed]
  4. 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 [PubMed]
    2. Indication
      1. Hypertension (Blood Pressure >130/80 mmHg)
      2. Proteinuria
        1. Diabetes Mellitus
          1. Microalbuminuria in Diabetes Mellitus (Diabetic Nephropathy)
        2. Non-Diabetic
          1. Proteinuria on Urinalysis (1+ Protein on Urinalysis or >1 gram per day)
          2. Random Protein to Creatinine ratio >200 mg Protein/g Creatinine
    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
  5. 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)

VII. References

  1. (2002) Am J Kidney Dis 39:S1
  2. Rivera (2012) Am Fam Physician 86(8): 749-54 [PubMed]
  3. Snively (2004) Am Fam Physician 70:1921-30 [PubMed]
  4. Stigant (2003) CMAJ 168:1553-60 [PubMed]

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