How to manage a small atrophic kidney with severely impaired perfusion and cortical function, indicative of chronic kidney disease (CKD) and impaired renal function?

From the Guidelines

Management of a small atrophic kidney with severely impaired perfusion and cortical function requires a comprehensive approach focused on preserving remaining kidney function and preventing further deterioration, with the primary treatment strategy involving controlling blood pressure with medications such as ACE inhibitors or ARBs, as recommended by recent guidelines 1.

Key Considerations

• Controlling blood pressure is crucial to reduce pressure within the kidney's filtering units and minimize protein leakage, with medications such as ACE inhibitors (like enalapril 5-20 mg daily or lisinopril 10-40 mg daily) or ARBs (such as losartan 25-100 mg daily) 1.
• Dietary modifications are essential, including sodium restriction to less than 2,300 mg daily, moderate protein intake (0.8 g/kg body weight), and adequate hydration, to support kidney function and prevent further decline 1.
• Regular monitoring of kidney function through blood tests (creatinine, BUN, eGFR) every 3-6 months is crucial to track disease progression and adjust treatment as needed 1.
• Patients should avoid nephrotoxic medications like NSAIDs and certain antibiotics that can further damage kidney tissue, and consider alternative therapies such as sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists for patients with diabetic kidney disease 1.

Disease Progression and Renormalization

• This condition often represents irreversible kidney damage from conditions like chronic hypertension, diabetes, or glomerulonephritis, where the kidney has scarred and shrunk, and may require preparation for renal replacement therapy (dialysis or transplantation) if both kidneys are affected and function continues to decline 1.
• The glomerular filtration rate (GFR) is a critical indicator of kidney function, and a decline below 15 ml/min may indicate the need for renal replacement therapy 1.

Clinical Guidelines and Recommendations

• Recent clinical guidelines recommend the use of sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists for patients with diabetic kidney disease to provide both kidney and cardiovascular protective benefits 1.
• An integrated approach to patient care with a multidisciplinary focus can help achieve the necessary shift in clinical care of patients with chronic kidney disease, and improve outcomes in terms of morbidity, mortality, and quality of life 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Management of Small Atrophic Kidney with Severely Impaired Perfusion and Cortical Function

• The management of a small atrophic kidney with severely impaired perfusion and cortical function, indicative of chronic kidney disease (CKD) and impaired renal function, involves the use of angiotensin receptor blockers (ARBs) or angiotensin-converting enzyme inhibitors (ACEIs) to slow the progression of CKD 2, 3, 4.
• ARBs have been shown to be effective in improving renal function and reducing proteinuria in patients with CKD, with telmisartan providing superior reductions in proteinuria compared to losartan 2.
• The use of ACEIs/ARBs is common in all stages of CKD, with over 50% of patients in the CKD-at-risk group and in CKD stages 1-5 being prescribed these medications 3.
• Monitoring of serum creatinine and potassium is important in patients with CKD, with Scr being monitored in 91.6% of ACEI/ARB-treated patients, while potassium was monitored in only 38.1% 3.
• The fear of hyperkalemia or acute renal decline is a factor that may limit the use of RAS blockers in patients with advanced CKD, but studies have shown that the use of high doses of ACEI/ARB and their up-titration in patients with CHF and CKD III/IV may be appropriate provided that the patient is adequately monitored 4, 5.
• Renal cortical imaging with Tc-99m DMSA may be useful in evaluating the functional and morphological status of the renal cortex, particularly in children with urinary tract infections or congenital urinary tract anomalies 6.

Treatment Options

• Angiotensin receptor blockers (ARBs) such as irbesartan, losartan, telmisartan, and valsartan may be used to manage CKD 2.
• Angiotensin-converting enzyme inhibitors (ACEIs) may also be used to manage CKD, particularly in patients with hypertension and/or diabetes 2, 3, 4.
• The use of high doses of ACEI/ARB and their up-titration in patients with CHF and CKD III/IV may be appropriate provided that the patient is adequately monitored 5.

Monitoring and Follow-up

• Regular monitoring of serum creatinine and potassium is important in patients with CKD, particularly those being treated with ACEIs/ARBs 3.
• Renal function should be monitored regularly, with changes in renal function being evaluated as a function of both baseline ACEI/ARB dose and dose change from baseline 5.