What is the diagnosis for Chronic Kidney Disease (CKD), likely due to ischemic atherosclerosis?

From the Guidelines

Chronic Kidney Disease (CKD) due to ischemic angiosclerosis requires comprehensive management focusing on slowing disease progression and managing complications, with a priority on blood pressure control using ACE inhibitors or ARBs, lifestyle modifications, and monitoring of kidney function. The management of CKD involves a multifaceted approach, including the use of medications that provide renoprotection, such as ACE inhibitors (like lisinopril 10-40 mg daily) or ARBs (such as losartan 50-100 mg daily), which have been shown to slow the progression of kidney disease 1. Target blood pressure should be <130/80 mmHg, as recommended by recent guidelines 1. Lifestyle modifications are essential, including sodium restriction (<2g/day), smoking cessation, regular exercise, and weight management.

Key Management Strategies

• Monitor kidney function with regular creatinine, eGFR, and urine albumin-to-creatinine ratio tests every 3-6 months
• Consider statin therapy (atorvastatin 20-40 mg daily) for cardiovascular protection, regardless of baseline cholesterol levels 1
• If diabetes is present, optimize glycemic control with medications that have proven renal benefits, such as SGLT2 inhibitors (empagliflozin 10-25 mg daily) 1
• Be vigilant for complications like anemia, metabolic acidosis, and mineral bone disorders, which require specific treatments

Referral and Follow-Up

Nephrology referral is recommended for eGFR <30 ml/min/1.73m² or rapidly declining kidney function, as these patients require more intensive management and monitoring 1. Ischemic angiosclerosis involves small vessel disease from hypertension and atherosclerosis, causing reduced blood flow to the kidneys and progressive scarring, highlighting the importance of early intervention and management 1.

From the Research

Chronic Kidney Disease (CKD) and Ischemic Angiosclerosis

• CKD is a long-term condition that occurs as a result of damage to the kidneys, and its early recognition is becoming increasingly common due to widespread laboratory estimated glomerular filtration rate (eGFR) reporting and raised clinical awareness 2.
• The management of CKD in patients with type 2 diabetes aims to preserve kidney function, reduce the risk of end-stage kidney disease, cardiovascular events, and mortality, and evidence-based recommendations include regular screening and lifestyle and pharmacological approaches 3.

Treatment of CKD

• Angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB) are two classes of antihypertensive drugs that act on the renin-angiotensin-aldosterone system, and their beneficial effects on kidney outcomes and survival in people with a wide range of severity of kidney impairment have been reported 2, 4.
• However, the effectiveness of ACEi and ARB in patients with early CKD (stage 1 to 3) is less certain, and the available evidence is overall of very low certainty and high risk of bias 2.
• ACEi monotherapy has been shown to significantly decrease the odds of kidney events, cardiovascular events, cardiovascular death, and all-cause death in non-dialysis CKD stages 3-5 patients compared to placebo 4.

Risks and Benefits of ACEi and ARB

• The use of ACEi and ARB is associated with a higher risk of hyperkalemia, cough, and hypotension, but they are still superior to other antihypertensive drugs in preventing kidney events, cardiovascular outcomes, cardiovascular death, and all-cause mortality in non-dialysis CKD3-5 patients 4.
• Exposure to ACEi or ARB after acute kidney injury (AKI) is associated with lower risks of all-cause mortality, recurrent AKI, and progression to incident CKD, but a higher incidence of hyperkalemia associated with ACEi/ARB usage among these patients deserves close clinical monitoring 5.

CKD and Cardiovascular Disease

• Patients with CKD are at high risk of cardiovascular disease, and the management of CKD aims to reduce this risk through lifestyle and pharmacological approaches, including the use of ACEi and ARB 3, 4.
• The use of ACEi and ARB has been shown to reduce the risk of cardiovascular events and death in patients with CKD, but the evidence is not consistent across all studies, and further research is needed to determine the optimal treatment strategies for patients with CKD and cardiovascular disease 2, 4.