How to lower creatinine levels?

How to Lower Creatinine Levels

The most effective strategy to lower creatinine and slow chronic kidney disease progression is optimizing glucose control in diabetic patients, combined with SGLT2 inhibitors for those with type 2 diabetes and kidney disease, ACE inhibitors or ARBs for those with hypertension and albuminuria, and blood pressure optimization to targets below 130/80 mmHg. 1

Primary Pharmacologic Interventions

For Diabetic Kidney Disease

SGLT2 Inhibitors (First-Line)

• Use SGLT2 inhibitors in type 2 diabetes patients with eGFR ≥20 mL/min/1.73 m² and urinary albumin ≥200 mg/g creatinine to reduce CKD progression and cardiovascular events 1
• These agents slow kidney disease progression without increasing acute kidney injury risk, even when combined with diuretics 1
• For patients unable to use SGLT2 inhibitors, finerenone (nonsteroidal MRA) reduces CKD progression and cardiovascular events 1

Glucose Optimization

• Optimize glucose control as this directly reduces risk and slows CKD progression 1
• This is a Grade A recommendation across all major diabetes guidelines 1

For Patients with Hypertension and Albuminuria

ACE Inhibitors or ARBs

• Strongly recommended for urinary albumin-to-creatinine ratio ≥300 mg/g creatinine and/or eGFR <60 mL/min/1.73 m² 1
• Recommended for modestly elevated albuminuria (30-299 mg/g creatinine) 1
• Critical caveat: Do NOT discontinue these medications for creatinine increases ≤30% in the absence of volume depletion—this represents altered hemodynamics, not acute kidney injury 1
• The ACCORD BP trial demonstrated that creatinine increases up to 30% with intensive blood pressure lowering did not increase mortality or progressive kidney disease 1

Blood Pressure Management

Target and Strategy

• Optimize blood pressure control with target <130/80 mmHg to reduce risk or slow CKD progression 1
• Reduce blood pressure variability, not just absolute values 1
• Expect to require 3-4 antihypertensive medications to achieve target blood pressure in CKD patients 1
• Monitor serum creatinine and potassium periodically when using ACE inhibitors, ARBs, or diuretics 1

Dietary Modifications

Protein Restriction

• Limit dietary protein to maximum 0.8 g/kg body weight per day (the recommended daily allowance) for non-dialysis-dependent stage 3 or higher CKD 1
• Meta-analysis demonstrates reduced risk of CKD progression with low-protein diets 1
• Important mechanism: Protein restriction reduces creatinine production and excretion, which lowers serum creatinine independent of GFR changes 2, 3
• Studies show protein intake directly correlates with creatinine clearance (r = 0.8; P < 0.0001) and creatinine excretion 3

Sodium Restriction

• Dietary sodium restriction reduces urinary protein excretion, which correlates with slower loss of kidney function 1

Monitoring and Avoiding Pitfalls

What NOT to Do

• Do not discontinue RAS blockade (ACE inhibitors/ARBs) for minor creatinine increases (≤30%) without volume depletion 1
• Do not confuse creatinine elevations from RAS blockers with acute kidney injury—these represent altered glomerular hemodynamics, not kidney damage 1
• Avoid nephrotoxins including NSAIDs and minimize iodinated contrast exposure 1

Monitoring Schedule

• Assess urinary albumin and eGFR at least annually in all type 2 diabetes patients and type 1 diabetes patients with duration ≥5 years 1
• Monitor twice annually if urinary albumin >30 mg/g creatinine and/or eGFR <60 mL/min/1.73 m² 1
• Monitor serum potassium periodically in patients on ACE inhibitors, ARBs, or MRAs with eGFR <60 mL/min/1.73 m² 1

Albuminuria Reduction Target

Specific Goal

• Achieve ≥30% reduction in urinary albumin (mg/g) to slow CKD progression in patients with ≥300 mg/g urinary albumin 1
• Reductions in urinary protein excretion correlate with slower loss of kidney function 1

Understanding Creatinine Changes

Context Matters

• Creatinine levels reflect both kidney function AND muscle mass/protein intake 4, 2, 3
• Low-protein diets reduce creatinine secretion and excretion, causing differences in creatinine clearance that are not due to GFR changes 2
• Antihypertensive therapy affects creatinine secretion: low blood pressure goals slow the decline in creatinine secretion 2
• Baseline serum creatinine ≥1.7 mg/dL carries significant prognostic value, with 8-year mortality more than three times higher than other patients 5