What treatments are used to protect kidney function in patients with impaired renal function?

Treatments to Protect Kidney Function in Patients with Impaired Renal Function

The most effective treatments to protect kidney function in patients with impaired renal function include renin-angiotensin system blockers (ACE inhibitors or ARBs), strict blood pressure control, and lifestyle modifications targeting metabolic factors. 1

Pharmacological Interventions

Renin-Angiotensin System (RAS) Modulation

• ACE inhibitors and ARBs are first-line agents for kidney protection in patients with impaired renal function, particularly those with proteinuria 1
• For type 2 diabetes with overt nephropathy, angiotensin receptor blockers (ARBs) are preferred for kidney function preservation 1
• For type 1 diabetes (with or without nephropathy), type 2 diabetes without overt nephropathy, and non-diabetic chronic kidney disease (CKD), ACE inhibitors are the RAS modulator of choice 1
• When initiating these medications, expect an initial 10-20% increase in serum creatinine, which is not a reason to discontinue therapy unless the increase exceeds 20% 1

Blood Pressure Control

• Target blood pressure should be <130/80 mmHg in patients with CKD, especially those with proteinuria >1 g/day 1
• Multiple antihypertensive drugs are typically required to achieve target blood pressure in patients with diabetes and/or reduced kidney function 1
• Aggressive blood pressure control is warranted even in patients with proteinuria below 300 mg/day due to high risk of cardiovascular disease 1

Cautions with Medication Use

• Monitor for hyperkalemia when using RAS blockers, especially in patients with renal insufficiency, diabetes mellitus, or when combined with potassium-sparing diuretics 2, 3
• Avoid dual RAS blockade (combining ACE inhibitors with ARBs) as this increases risks of hyperkalemia, hypotension, and acute kidney injury without additional benefits 3
• Use NSAIDs cautiously as they can worsen kidney function, especially in elderly or volume-depleted patients 2, 3

Non-Pharmacological Interventions

Dietary Modifications

• Reduce dietary sodium intake to help control blood pressure and slow kidney function decline 1, 4
• A low-salt diet appears to reduce the risk of renal composite outcomes in CKD patients 4
• Consider plant-based diets which may improve kidney disease complications and potentially affect disease progression favorably 5

Weight Management and Exercise

• Weight loss and exercise interventions in obese CKD patients can improve insulin sensitivity, reduce inflammation, and potentially preserve kidney function 6
• Lifestyle modifications addressing physical inactivity, obesity, and high caloric intake are fundamental to preventing hypertension-related kidney complications 1

Preserving Residual Kidney Function

In Dialysis Patients

• Preserve residual kidney function in dialysis patients through:
  • Avoiding nephrotoxic agents (aminoglycosides, radiocontrast agents) 1
  • Using ACE inhibitors or ARBs when antihypertensive therapy is indicated 1
  • Maintaining hemodynamic stability during hemodialysis to avoid episodes of intravascular volume depletion 1
  • Using biocompatible dialysis membranes and ultrapure water 1

In Transplant Recipients

• For liver transplant recipients, strategies to protect kidney function include:
  • Delay and reduction of calcineurin inhibitor (CNI) exposure in the perioperative period 1
  • Early CNI reduction (1-12 months post-transplant) combined with non-nephrotoxic immunosuppressive agents 1
  • Monitoring for donor-specific antibodies in simultaneous liver-kidney transplant recipients 1

Common Pitfalls and Caveats

• Be vigilant for acute kidney injury when using ACE inhibitors or ARBs in patients with:
  • Bilateral renal artery stenosis or stenosis of a dominant/single kidney 1
  • Volume depletion or concomitant use of NSAIDs 1, 2
  • Severe heart failure with systolic blood pressure below 100 mmHg 2
• Initial decrease in GFR with ACE inhibitors/ARBs is expected and represents their therapeutic effect; discontinuation is not necessary unless the decrease exceeds 20% 1
• Patients with diabetes require special attention with multiple antihypertensive drugs and careful glycemic control using appropriate agents as renal function declines 7

By implementing these pharmacological and non-pharmacological strategies, healthcare providers can significantly improve outcomes for patients with impaired renal function, reducing the risk of progression to end-stage renal disease and associated complications.