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

From the Guidelines

The treatment of Chronic Kidney Disease (CKD) should focus on a comprehensive approach to reduce the risk of kidney disease progression and cardiovascular disease, as recommended by the KDIGO 2022 clinical practice guideline for diabetes management in CKD 1.

Key Components of CKD Management

• Blood pressure control with ACE inhibitors or ARBs, which reduce proteinuria and slow kidney function decline
• Dietary modifications, including sodium restriction, protein moderation, and potassium limitation
• Glycemic control for diabetic patients, targeting HbA1c of 7-7.5%
• Lifestyle modifications, such as optimizing physical activity, weight management, and avoidance of tobacco products
• First-line drug therapy with SGLT2 inhibitors, statins, and RAS inhibitors, as indicated by the KDIGO 2024 clinical practice guideline for the evaluation and management of CKD 1

Additional Therapies

• GLP-1 receptor agonists for patients with type 2 diabetes who are unable to achieve glycemic targets with metformin and SGLT2 inhibitors
• Nonsteroidal mineralocorticoid receptor antagonists for patients with high residual risks of kidney disease progression and cardiovascular events
• Antiplatelet therapies for patients with established cardiovascular disease or high risk of atherosclerotic cardiovascular disease

Monitoring and Referral

• Regular monitoring of kidney function, electrolytes, and complications
• Referral to nephrology when GFR falls below 30ml/min/1.73m² The KDIGO 2021 clinical practice guideline for the management of blood pressure in CKD also recommends starting RAS inhibitors for patients with high blood pressure, CKD, and severely increased albuminuria, with or without diabetes 1. However, the most recent and highest-quality study, the KDIGO 2024 clinical practice guideline, provides a more comprehensive approach to CKD management, emphasizing the importance of lifestyle modifications, first-line drug therapy, and targeted therapies for complications 1.

From the FDA Drug Label

In controlled trials, patients experienced greater risks for death, serious adverse cardiovascular reactions, and stroke when administered ESAs to target a hemoglobin level of greater than 11 g/dL. No trial has identified a hemoglobin target level, ESA dose, or dosing strategy that does not increase these risks Individualize dosing and use the lowest dose of PROCRIT sufficient to reduce the need for RBC transfusions For all patients with CKD: When initiating or adjusting therapy, monitor hemoglobin levels at least weekly until stable, then monitor at least monthly For adult patients with CKD on dialysis: Initiate PROCRIT treatment when the hemoglobin level is less than 10 g/dL. If the hemoglobin level approaches or exceeds 11 g/dL, reduce or interrupt the dose of PROCRIT. The recommended starting dose for adult patients is 50 to 100 Units/kg 3 times weekly intravenously or subcutaneously. For adult patients with CKD not on dialysis: Consider initiating PROCRIT treatment only when the hemoglobin level is less than 10 g/dL If the hemoglobin level exceeds 10 g/dL, reduce or interrupt the dose of PROCRIT, and use the lowest dose of PROCRIT sufficient to reduce the need for RBC transfusions. The recommended starting dose for adult patients is 50 to 100 Units/kg 3 times weekly intravenously or subcutaneously.

The treatment of Chronic Kidney Disease (CKD) with epoetin alfa (IV) involves:

• Initiating treatment when the hemoglobin level is less than 10 g/dL
• Monitoring hemoglobin levels at least weekly until stable, then at least monthly
• Individualizing dosing and using the lowest dose sufficient to reduce the need for RBC transfusions
• Reducing or interrupting the dose if the hemoglobin level approaches or exceeds 11 g/dL
• Starting dose of 50 to 100 Units/kg 3 times weekly intravenously or subcutaneously for adult patients with CKD on dialysis or not on dialysis 2 2

From the Research

Treatment of Chronic Kidney Disease (CKD)

The treatment of CKD involves a combination of lifestyle modifications, nutritional and therapeutic interventions. Some of the key aspects of CKD treatment include:

• Blood pressure control: 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 3.
• Glycemic control: Controlling blood sugar levels is crucial in preventing the progression of CKD, especially in patients with diabetes 3, 4.
• Lifestyle modifications: Lifestyle changes such as walking, weight loss, low-protein diet, adherence to the alternate Mediterranean diet, and Alternative Healthy Eating Index (AHEI)-2010 can slow the progression of CKD 3, 5.
• Medications: Medical therapies 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 3.
• Renin-angiotensin system (RAS) blockers: RAS blockers, such as angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs), are the main drugs used to achieve blood pressure control and reduce albuminuria in CKD patients 6.

Lifestyle Behavior Change

Lifestyle behavior change is an essential aspect of CKD treatment. Some of the key elements of lifestyle behavior change include:

• Education: Education is the most frequently used function in lifestyle interventions for CKD patients 7.
• Goal setting: Goal setting is a crucial behavior change technique used in lifestyle interventions for CKD patients 7.
• Feedback and monitoring: Feedback and monitoring are essential behavior change techniques used in lifestyle interventions for CKD patients 7.
• Social support: Social support is a critical behavior change technique used in lifestyle interventions for CKD patients 7.

Medications and Therapies

Several medications and therapies are used to treat CKD, including:

• RAAS blockers: RAAS blockers are used to achieve blood pressure control and reduce albuminuria in CKD patients 3, 6.
• SGLT2 inhibitors: SGLT2 inhibitors are used to manage CKD, especially in patients with diabetes 3.
• Pentoxifylline: Pentoxifylline is used to manage CKD, especially in patients with inflammation 3.
• Finerenone: Finerenone is used to manage CKD, especially in patients with hyperkalemia 3.
• Atrasentan: Atrasentan, an endothelin receptor antagonist (ERA), has been shown to decrease the risk of renal events in diabetic CKD patients 3.