From the Guidelines
The treatment of chronic kidney disease (CKD) should prioritize a comprehensive approach to reduce risks of kidney disease progression and cardiovascular disease, as recommended by the KDIGO 2022 clinical practice guideline for diabetes management in CKD 1. This approach includes lifestyle modification and self-management, first-line drug therapies such as metformin and sodium-glucose cotransporter-2 (SGLT2) inhibitors for patients with type 2 diabetes, and renin-angiotensin system (RAS) inhibition for patients with albuminuria and hypertension.
- Key components of CKD management include:
- Blood pressure control below 130/80 mmHg
- Glycemic control using metformin and SGLT2 inhibitors for patients with type 2 diabetes
- Lipid management with statins
- Antiplatelet therapies for patients with atherosclerotic cardiovascular disease (ASCVD)
- Lifestyle modifications such as diet, exercise, and smoking cessation
- SGLT2 inhibitors should be initiated when estimated glomerular filtration rate (eGFR) is ≥ 20 ml/min per 1.73 m² and continued as tolerated, until dialysis or transplantation is initiated, as recommended by the KDIGO 2022 guideline 1.
- Additionally, glucagon-like peptide-1 receptor agonists (GLP-1 RA) can be used as preferred glucose-lowering drugs for people with type 2 diabetes if SGLT2 inhibitors and metformin are insufficient to meet glycemic targets or if they are unable to use SGLT2 inhibitors or metformin.
- Regular monitoring of kidney function, electrolytes, and metabolic parameters is essential, with referral to nephrology recommended at stage 3b (eGFR <45 ml/min/1.73m²) or earlier with rapid progression or complications, as supported by the KDIGO controversies conference conclusions 1.
- Kidney replacement therapy planning should begin at stage 4 (eGFR <30 ml/min/1.73m²) to ensure timely access placement for dialysis or evaluation for transplantation, as emphasized by the KDIGO 2022 guideline 1.
From the Research
Treatment of CKD
The treatment of Chronic Kidney Disease (CKD) involves a multifaceted approach that includes lifestyle modifications, nutritional and therapeutic interventions.
- Lifestyle modifications such as walking, weight loss, low-protein diet (LPD), adherence to the alternate Mediterranean (aMed) diet, and Alternative Healthy Eating Index (AHEI)-2010 can slow the progression of CKD 2.
- Additionally, controlling hypertension and diabetes mellitus, and avoiding smoking and binge alcohol drinking are also crucial in delaying the progression of CKD 2, 3.
- The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommend blood pressure control of <140/90 mmHg in patients without albuminuria and <130/80 mmHg in patients with albuminuria to prevent CKD progression 2, 3.
Medical Therapies
Medical therapies for CKD aim to target epigenetic alterations, fibrosis, and inflammation.
- Currently, RAAS blockade, sodium-glucose cotransporter-2 (SGLT2) inhibitors, pentoxifylline, and finerenone are approved for managing CKD 2.
- Other agents such as atrasentan, an endothelin receptor antagonist (ERA), have also shown promise in decreasing the risk of renal events in diabetic CKD patients 2.
- A comparative study found that initiating renin-angiotensin system (RAS) inhibitor therapy in patients with advanced CKD may be superior to alternative antihypertensive agents such as calcium channel blockers (CCBs) in reducing the risk of kidney replacement therapy (KRT) 4.
Lifestyle Interventions
Lifestyle interventions such as diet, exercise, and other lifestyle-related interventions can also positively affect some risk factors for progression of CKD and quality of life.
- A systematic review and meta-analysis found that lifestyle interventions resulted in significant improvements in creatinine, 24-hour albuminuria, systolic blood pressure, diastolic blood pressure, and body weight 5.
- Another study found that maintaining a healthy lifestyle remains a cornerstone of CKD management given the undisputed benefits of healthy lifestyle behaviors on cardiovascular health, BP control, and survival 6.