What are the treatment options for Chronic Kidney Disease (CKD)?

From the Guidelines

Treatment for chronic kidney disease should focus on slowing disease progression and managing complications, with a comprehensive approach that includes lifestyle modification, smoking cessation, RAS inhibition, optimization of blood pressure control, statins, optimization of glycemic control, and treatment of underlying causes, as recommended by the most recent and highest quality study 1.

Key Components of Treatment

• Lifestyle modification, including dietary changes and increased physical activity
• Smoking cessation to reduce cardiovascular risk
• RAS inhibition, such as ACE inhibitors or ARBs, to reduce proteinuria and blood pressure
• Optimization of blood pressure control, with a target blood pressure below 130/80 mmHg
• Statins to reduce cardiovascular risk, although they should not be initiated in patients starting dialysis therapy 1
• Optimization of glycemic control, with consideration of SGLT2 inhibitors and GLP-1 receptor agonists for patients with type 2 diabetes 1

Additional Considerations

• Treatment of underlying causes, such as diabetes and hypertension
• Avoidance of nephrotoxic medications, such as NSAIDs and certain antibiotics
• Regular monitoring of kidney function, electrolytes, and complications, with adjustments to medication dosages as kidney function declines
• Preparation for renal replacement therapy, either dialysis or kidney transplantation, in advanced disease (stages 4-5)

Recent Guidelines and Recommendations

• The KDIGO 2020 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease recommends a comprehensive approach to managing diabetes in patients with CKD, including lifestyle modification, pharmacologic therapy, and regular monitoring 1
• The Mayo Clinic Proceedings review on diabetic kidney disease highlights the importance of early detection and treatment, and recommends the use of SGLT2 inhibitors and GLP-1 receptor agonists to reduce the risk of kidney disease progression and cardiovascular events 1

From the FDA Drug Label

In controlled trials, patients experienced greater risks for death, serious adverse cardiovascular reactions, and stroke when administered ESAs to target a hemoglobin level of greater than 11 g/dL. No trial has identified a hemoglobin target level, ESA dose, or dosing strategy that does not increase these risks Individualize dosing and use the lowest dose of PROCRIT sufficient to reduce the need for RBC transfusions [see Warnings and Precautions (5. 1)] . For adult patients with CKD on dialysis: Initiate PROCRIT treatment when the hemoglobin level is less than 10 g/dL. If the hemoglobin level approaches or exceeds 11 g/dL, reduce or interrupt the dose of PROCRIT. The recommended starting dose for adult patients is 50 to 100 Units/kg 3 times weekly intravenously or subcutaneously.

The treatment for chronic kidney disease (CKD) with epoetin alfa (IV) involves using the lowest dose sufficient to reduce the need for red blood cell (RBC) transfusions.

• The recommended starting dose for adult patients with CKD is 50 to 100 Units/kg 3 times weekly intravenously or subcutaneously.
• For patients with CKD on dialysis, initiate treatment when the hemoglobin level is less than 10 g/dL.
• If the hemoglobin level approaches or exceeds 11 g/dL, reduce or interrupt the dose of PROCRIT 2 2. Key considerations:
• Evaluate iron status before and during treatment and maintain iron repletion.
• Correct or exclude other causes of anemia before initiating treatment.
• Monitor hemoglobin levels at least weekly until stable, then monitor at least monthly.

From the Research

Treatment Options for Chronic Kidney Disease

• Lifestyle modifications such as walking, weight loss, and adherence to a low-protein diet or the alternate Mediterranean diet can slow the progression of CKD 3
• Controlling hypertension and diabetes mellitus through medications and lifestyle changes is crucial in delaying CKD progression 3, 4
• The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommend blood pressure control of <140/90 mmHg in patients without albuminuria and <130/80 mmHg in patients with albuminuria to prevent CKD progression 3

Medical Therapies for CKD

• Renin-angiotensin-aldosterone system (RAAS) blockade, sodium-glucose cotransporter-2 (SGLT2) inhibitors, pentoxifylline, and finerenone are approved for managing CKD 3
• Atrasentan, an endothelin receptor antagonist, has been shown to decrease the risk of renal events in diabetic CKD patients 3
• SGLT2 inhibitors can prevent CKD progression and reduce fatal and non-fatal kidney and cardiovascular events, hospitalization for heart failure, and all-cause mortality 5

Importance of Early Diagnosis and Referral

• Early diagnosis and immediate nephrology referral are key steps in CKD management, enabling predialysis education and implementation of preventive measures 6
• Primary care practitioners play a crucial role in the early identification and management of patients with CKD, particularly in individuals at high risk of CKD 5
• A multifaceted approach is required to ensure that people with CKD receive optimal kidney protection, including lifestyle modifications, guideline-directed medical therapy, and good interdisciplinary communication 5

Educational Interventions for CKD Management

• Educational programs with a multidisciplinary health-care approach supported by self-help groups can improve lifestyle and dietary habits in patients at high risk of developing CKD 4
• Educational interventions by both doctors and patients should be adopted concurrently to help control the growing problem of end-stage renal disease 4