What are the primary goals and therapies for managing kidney disease, including medications and interventions for patients with chronic kidney disease and end-stage renal disease?

Primary Goals and Therapies for Managing Kidney Disease

The primary goals of chronic kidney disease (CKD) management are to delay disease progression, prevent complications, reduce cardiovascular risk, and improve quality of life through a comprehensive treatment strategy that includes lifestyle modifications, pharmacotherapy, and appropriate renal replacement therapy when needed. 1

Goals of CKD Management

• Delay progression of kidney disease through targeted interventions 1
• Treat specific kidney diseases (e.g., glomerulonephritis, polycystic kidney disease) 1
• Manage CKD-specific complications (anemia, metabolic bone disease, acidosis) 1
• Reduce cardiovascular risk, which is significantly elevated in CKD patients 1
• Plan and prepare for kidney replacement therapy when appropriate 1
• Empower patients through education and shared decision-making 1

First-Line Therapies for CKD Management

Lifestyle Modifications

• Optimize physical activity and weight management to improve overall health outcomes 1
• Implement healthy dietary patterns, with consideration for plant-based diets when appropriate 1
• Avoid tobacco products to reduce cardiovascular risk 1
• Maintain protein intake at 0.8 g/kg body weight per day for non-dialysis CKD patients (avoid high protein >1.3 g/kg/day which can accelerate kidney function decline) 1
• Restrict dietary sodium to <2,300 mg/day to control blood pressure and reduce cardiovascular risk 1

Pharmacological Interventions

• SGLT2 inhibitors should be first-line therapy for most CKD patients to slow disease progression, regardless of diabetes status 1, 2
• Renin-angiotensin system (RAS) inhibitors (ACE inhibitors or ARBs) at maximum tolerated doses for patients with hypertension, particularly those with albuminuria 1, 3
• Blood pressure control with a target systolic BP <120 mmHg to reduce risk of CKD progression 1
• Add dihydropyridine calcium channel blockers and/or diuretics as needed to achieve BP targets 1
• Statin therapy for cardiovascular risk reduction 1
• For diabetic patients, optimize glycemic control (target A1C <7%) and consider GLP-1 receptor agonists which have shown kidney-protective effects 1, 2
• Use nonsteroidal mineralocorticoid receptor antagonists in people with diabetes for additional kidney protection 1

Management of CKD Complications

Anemia Management

• Monitor hemoglobin regularly; treatment is indicated when hemoglobin falls below target levels 1
• Iron supplementation should be considered before or in conjunction with erythropoiesis-stimulating agents 1
• Target hemoglobin concentration of 11-12 g/dL to improve quality of life while avoiding cardiovascular risks of higher targets 4

Mineral and Bone Disorder Management

• Monitor serum calcium, phosphate, PTH, and vitamin 25(OH)D levels 1
• Implement dietary phosphate restrictions when indicated 4
• Use phosphate binders and vitamin D supplementation as needed 4
• Consider referral for parathyroidectomy when medical therapy fails 4

Metabolic Acidosis Management

• Monitor serum bicarbonate levels regularly 1
• Treat metabolic acidosis with oral alkali supplementation to maintain serum bicarbonate within normal range 1

Electrolyte Abnormalities

• Monitor serum potassium, especially in patients on RAS inhibitors, diuretics, or MRAs 1
• Individualize dietary potassium restrictions based on serum levels 1
• Consider potassium binders for persistent hyperkalemia 1

Renal Replacement Therapy for End-Stage Renal Disease (ESRD)

• Timely planning for kidney replacement therapy is essential for optimal outcomes 1
• Options include:
  • Peritoneal dialysis: Home-based therapy with comparable long-term mortality to hemodialysis 5
  • Hemodialysis: Typically performed at dialysis centers through vascular access (arteriovenous fistula preferred due to lower infection risk) 5
  • Kidney transplantation: The treatment of choice for eligible ESRD patients, offering better quality of life and survival 5
• Supportive care without dialysis is a valid option for some patients, requiring palliative care referral 5

Integrated Care Approach

• Implement a team approach with nephrologists, primary care providers, dietitians, pharmacists, and other specialists 1
• Regular risk factor reassessment every 3-6 months 1
• Prioritize patient concerns, values, and preferences in treatment decisions 1
• Provide comprehensive medication management, including dose adjustments for kidney function, medication reconciliation, and deprescribing when appropriate 1

Common Pitfalls to Avoid

• Delaying nephrology referral for advanced CKD (eGFR <30 mL/min/1.73m²) 1
• Inadequate blood pressure control or failure to use RAS inhibitors when indicated 6
• Overlooking the importance of lifestyle modifications alongside pharmacotherapy 1
• Insufficient monitoring of medication dosing in CKD, leading to adverse effects 7
• Failure to prepare patients for renal replacement therapy in a timely manner 1
• Neglecting to screen for and manage CKD complications until they become severe 1

By implementing this comprehensive approach to CKD management, clinicians can significantly improve outcomes, reduce progression to ESRD, and enhance quality of life for patients with kidney disease.