What are the treatment options for stage 4 Chronic Kidney Disease (CKD)?

From the Guidelines

Treatment for stage 4 Chronic Kidney Disease (CKD) should prioritize a comprehensive approach focusing on slowing disease progression and managing complications, with interventions including lifestyle modification, smoking cessation, RAS inhibition, optimization of blood pressure control, statins, optimization of glycemic control, and treatment of underlying causes and metabolic acidosis, as recommended by the most recent guidelines 1.

Key Interventions

• Lifestyle modifications, such as dietary changes and increased physical activity, are crucial in managing CKD.
• Smoking cessation is essential to reduce cardiovascular risk and slow CKD progression.
• RAS inhibition, using ACE inhibitors or ARBs, is recommended for blood pressure control and to provide renoprotective effects, as supported by guidelines 2.
• Optimization of blood pressure control, typically aiming for targets below 130/80 mmHg, is vital in slowing CKD progression.
• Statins should be used to manage dyslipidemia, but their initiation is not recommended for patients starting dialysis therapy, as noted in 1.
• Optimization of glycemic control, targeting HbA1c levels of 7-8% for diabetic patients, is important in managing CKD.
• SGLT2 inhibitors and GLP-1 receptor agonists may be considered for patients with type 2 diabetes, as they have shown benefits in reducing cardiovascular risk and slowing CKD progression, as discussed in 1.

Additional Considerations

• Treatment of underlying causes, avoidance of nephrotoxins, and adjustment of medication dosages are critical in managing CKD.
• Metabolic acidosis should be treated to slow CKD progression and reduce the risk of complications.
• Regular monitoring of kidney function, electrolytes, and metabolic parameters every 3-6 months is essential in managing CKD.
• Patients should begin discussions about renal replacement therapy options, such as dialysis or transplantation, and establish vascular access if dialysis is anticipated, as recommended in 3.

Patient Education and Support

• Disease education via digital media and patient portals can facilitate patient self-management and communication with providers.
• Co-design of interventions with patients embedded in local communities is important for ensuring utility and acceptability, as noted in 1.

From the FDA Drug Label

The RENAAL study was a randomized, placebo-controlled, double-blind, multicenter study conducted worldwide in 1513 patients with type 2 diabetes with nephropathy (defined as serum creatinine 1.3 to 3.0 mg/dL in females or males ≤60 kg and 1.5 to 3. 0 mg/dL in males >60 kg and proteinuria [urinary albumin to creatinine ratio ≥300 mg/g]). Treatment with losartan resulted in a 16% risk reduction in the primary endpoint (doubling of serum creatinine, end-stage renal disease (ESRD), or death).

The treatment options for stage 4 Chronic Kidney Disease (CKD) may include losartan, which has been shown to reduce the risk of doubling of serum creatinine, end-stage renal disease (ESRD), and death by 16% in patients with type 2 diabetes and nephropathy 4.

• Losartan may be used to slow the progression of renal disease in patients with CKD.
• The use of losartan should be considered in the context of overall patient management, including blood pressure control and proteinuria reduction.

From the Research

Treatment Options for Stage 4 Chronic Kidney Disease (CKD)

The treatment options for stage 4 CKD can be summarized as follows:

• Blood pressure control using angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) has the greatest weight of evidence 5
• Glycemic control in diabetes seems likely to retard progression 5
• Several metabolic disturbances of CKD may prove to be useful therapeutic targets, including acidosis, hyperphosphatemia, and vitamin D deficiency 5
• ACEIs and ARBs are also being used to control proteinuria in early CKD patients, and have been shown to be effective in reducing proteinuria in normotensive patients 6
• The combination therapy of olmesartan+temocapril has been shown to be the most efficacious for reducing proteinuria in normotensive CKD patients and IgA nephropathy 6

Angiotensin-Converting Enzyme Inhibitors (ACEIs) and Angiotensin Receptor Blockers (ARBs)

• ACEIs and ARBs reduce proteinuria and slow renal disease progression more effectively than other therapies in patients with CKD 7
• Treatment with ACEI or ARB had a superior effect than no ACEI or ARB treatment on slowing kidney disease progression and on proteinuria reduction 7
• Efficacy of ACEI and ARB was comparable 7
• Withdrawal of ACEi/ARB treatment can stabilize or even improve renal function in patients with advanced progressive CKD, according to preliminary findings 8

Considerations for Older Adults

• Current guidelines for the use of ACEIs and ARBs in CKD are based on evidence with limited relevance to most persons older than 70 years with this condition 9
• The representation of older adults in randomized trials that underpin these guidelines is limited 9
• The characteristics of participants in these trials differ from those of a representative sample of older adults with CKD in the general population 9