Prevention of Kidney Disease Progression

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

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II. Protocols

  1. See Diabetic Nephropathy
  2. See Drug Dosing in Chronic Kidney Disease
  3. See Renal Osteodystrophy
  4. See Nephrotoxic Drugs
  5. See Intravenous Contrast Related Acute Renal Failure
  6. See Gadolinium-Associated Nephrogenic Systemic Fibrosis (Nephrogenic Fibrosing Dermopathy)

III. Management: Nephrology Consultation indications

  1. See Chronic Kidney Disease

IV. Management: Lifestyle, Diet and Health Maintenance

  1. Exercise
    1. Moderate intensity aerobic Exercise 150 minutes per week
    2. Resistance Training to prevent Sarcopenia
  2. General Diet
    1. Sodium Restriction 2000 to 2300 mg/day
    2. Plant-based diets with reduced animal Proteins are preferred
    3. Maintain adequate daily oral hydration
    4. Maintain adequate Caloric Intake per day and
      1. In Unintentional Weight Loss, minimum intake: 35 Kcal/kg/day
  3. Protein restriction (Stage 4 to 5, 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. Habits
    1. Tobacco Cessation
  5. Vaccination
    1. Influenza Vaccine
    2. Tetanus Vaccine
    3. Hepatitis B Vaccine
    4. Covid-19 Vaccine
    5. Recombinant Shingles Vaccine (Shingrix) if indicated
    6. Pneumococcal Conjugate Vaccine (e.g. PCV21)
      1. Includes age 19 to 64 years with ESRD
  6. Cancer Screening is not recommended in End Stage Renal Disease (ESRD)
    1. Life Expectancy in ESRD is not sufficient to warrant longterm cancer screening

V. Management: Hypertension and Proteinuria

  1. General
    1. Decreasing Blood Pressure and Proteinuria are the most important preventive measure in Chronic Kidney Disease
    2. Ambulatory or home Blood Pressure Measurements are preferred for BP monitoring over Hemodialysis center BPs
    3. Hypertension is common in ESRD
      1. Hypertension correlates with volume status
      2. Modify hemodilaysis to maintain normovolemia
  2. Goals of therapy
    1. Decrease Proteinuria by 50%
    2. Decrease Blood Pressure
      1. Goal BP in Chronic Kidney Disease is controversial
        1. KDIGO (2021): SBP <120 mmHg
        2. VA/DOD and JNC-8: BP<140/90 mmHg
        3. Prior guidelines recommended goal BP <130/80 mmHg
      2. References
      3. Arguedas (2009) Cochrane Database Syst Rev CD004349
      4. (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 (or Angiotensin Receptor Blocker) 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. eGFR <60 ml/min
          1. Urine Albumin to Creatinine Ratio >=30 mg/g for >3 month (per KDIGO 2024)
        3. 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. SGLT2 Inhibitor Indications (per KDIGO 2024)
    1. eGFR 20 to 60 ml/min AND
    2. One of the following:
      1. Urine Albumin to Creatinine Ratio >=200 mg/g (20 mg/mmol)
      2. Congestive Heart Failure
  6. 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)

VI. 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. Goal <8% is also effective in preventing Diabetic Nephropathy progression with fewer adverse effects
        2. Gerstein (2008) N Engl J Med 358(24): 2545-59 [PubMed]
    3. Maintain careful Blood Glucose Monitoring in ESRD (higher risk for Hypoglycemia)
      1. Hemodialysis typically helps improve Hyperglycemia management
      2. Hemoglobin A1C may be inaccurate in ESRD (esp. on Hemodialysis)
        1. Glucose monitoring logs are preferred
    4. Medications preferred when GFR>30 ml/min/1.73m2 (most are contraindicated for GFR<20 to 30 ml/min)
      1. SGLT2 Inhibitors (see above regarding Proteinuria)
      2. GLP1 Agonist
      3. Metformin
    5. Insulin is preferred in ESRD or GFR <20 to 30 ml/min/1.73m2
      1. Many other diabetic medications (e.g. Metformin) are contraindicated in low GFR
      2. Alternatives include Glipizide (but risk of Hypoglycemia) and Repaglinide
    6. Other measures to slow Diabetic Nephropathy progression
      1. Finerenone (Kerendia)
        1. Non-Steroidal Aldosterone Antagonist (mineralcorticoid receptor Antagonist)
        2. Contraindicated in Hyperkalemia (Serum Potassium >5.5 mEq/L)
        3. Indicated if Urine Albumin to Creatinine Ration >=30 mg/g AND eGFR>=25 ml/min (per KDIGO 2024)
  2. Coronary Artery Disease
    1. High Incidence of comorbidity
      1. Most ESRD patients die of Coronary Artery Disease before Dialysis
    2. General measures
      1. Aspirin 81 mg orally daily
      2. Statin for most patients
      3. Control Hypertension
    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. Statin Indications in addition to Hyperlipidemia (per KDIGO 2024)
      1. Age >= 50 years old OR
      2. Age 18 to 49 years old AND one of the following
        1. Diabetes Mellitus
        2. Cardiovascular disease
        3. Prior Ischemic Stroke
        4. 10 year Cardiovascular Risk score >10%
    3. Hyperlipidemia goals
      1. Goal LDL Cholesterol <100 mg/dl
      2. 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 (esp. Dehydration)
  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 and contraindicated medications at low GFR (<30 ml/min)
    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
    4. Other medication limitations for GFR <20 to 30 ml/min
      1. Avoid Metformin and Flozins (SGLT2 Inhibitors) in Type II Diabetes
      2. Avoid Bisphosphonates
      3. Avoid Direct Oral Anticoagulants
      4. Avoid NSAIDs
      5. For Bowel Preparation, use Polyethylene Glycol (PEG) instead of Magnesium or Phosphorus preparations
  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

VII. Management: End Stage Renal Disease Complications

  1. See End Stage Renal Disease
  2. Careful fluid balance (avoid Fluid Overload as well as Dehydration)
  3. Hyperkalemia
    1. Limit Dietary Potassium intake to 70 meq/day
  4. Metabolic Acidosis
    1. Treat if serum bicarbonate <20
  5. 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
  6. 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
  7. 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

VIII. References

  1. (2002) Am J Kidney Dis 39:S1
  2. (2024) Kidney Int 105(4S):S117-314 +PMID: 38490803 [PubMed]
  3. Goodbred (2023) Am Fam Physician 108(6): 554-61 [PubMed]
  4. Rivera (2012) Am Fam Physician 86(8): 749-54 [PubMed]
  5. Snively (2004) Am Fam Physician 70:1921-30 [PubMed]
  6. Stigant (2003) CMAJ 168:1553-60 [PubMed]

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