From the Guidelines
Vascular calcification, or hardening, should not be used as a treatment strategy in Chronic Kidney Disease (CKD) as it can lead to increased morbidity and mortality, and decreased quality of life 1.
Key Considerations
- The 2017 KDIGO CKD-MBD guideline update emphasizes the importance of managing CKD-MBD to prevent vascular calcification, rather than using it as a treatment strategy 1.
- The guideline recommends treating CKD-MBD based on serial assessments of phosphate, calcium, and PTH levels, considered together, to prevent vascular calcification and other complications 1.
- Lowering elevated phosphate levels toward the normal range, avoiding hypercalcemia, and maintaining serum calcium in the normal range are key strategies to prevent vascular calcification in CKD patients 1.
Treatment Strategies
- Phosphate-lowering treatment should be based on progressively or persistently elevated serum phosphate, and the choice of phosphate binder should take into account CKD stage, presence of other components of CKD-MBD, concomitant therapies, and side effect profile 1.
- Restricting the dose of calcium-based phosphate binders is recommended in adult patients with CKD G3a–G5D receiving phosphate-lowering treatment, especially in the presence of arterial calcification, adynamic bone disease, or persistently low serum PTH levels 1.
Monitoring and Management
- Regular monitoring of electrolyte levels, blood pressure, and kidney function is crucial when managing CKD patients to prevent complications such as vascular calcification 1.
- Healthcare providers should be aware of the potential risks and benefits of different treatment strategies and adjust their approach accordingly to prioritize morbidity, mortality, and quality of life outcomes 1.
From the Research
Vascular Calcification in Chronic Kidney Disease (CKD)
There is no direct evidence in the provided studies to support the use of hardening (vascular calcification) in Chronic Kidney Disease (CKD).
Management of CKD
- The renin-angiotensin-aldosterone system (RAAS) plays a pivotal role in many of the pathophysiologic changes that lead to progression of renal disease 2.
- Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) are two classes of antihypertensive drugs that act on the RAAS and have been shown to have beneficial effects on kidney outcomes and survival in people with CKD 3.
- The benefits of strict blood pressure control in slowing kidney disease progression have been demonstrated in several clinical trials, and ACEIs and ARBs are recommended as first-line agents in diabetic renal disease and non-diabetic renal disease with albuminuria 2.
Use of ACEIs and ARBs in CKD
- ACEIs and ARBs may be used in combination to reduce proteinuria in patients with kidney disease, but larger outcomes trials are needed to confirm their safety and efficacy 4.
- A network meta-analysis of randomized clinical trials found that ACEIs monotherapy significantly decreased the odds of kidney events, cardiovascular events, cardiovascular death, and all-cause death in non-dialysis CKD stages 3-5 patients compared to placebo 5.
- However, the certainty of the evidence for the effectiveness of ACEIs and ARBs in patients with stage 1 to 3 CKD who do not have diabetes mellitus is low, and more research is needed to determine their benefits and harms in this population 3.
Monitoring of Patients with CKD
- Patients with CKD who are treated with ACEIs or ARBs should be monitored regularly for changes in serum creatinine and potassium levels, as these medications can increase the risk of hyperkalemia and worsening renal function 6.