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 that includes lifestyle modification, first-line drug therapies, and additional interventions to control risk factors and improve kidney and cardiovascular outcomes, as recommended by the KDIGO 2022 clinical practice guideline for diabetes management in CKD 1. The management of CKD involves several key components, including:

• Glycemic control with metformin and sodium-glucose cotransporter-2 inhibitors (SGLT2i) for patients with type 2 diabetes (T2D) 1
• Blood pressure control with renin-angiotensin system (RAS) inhibition for patients with albuminuria and hypertension (HTN) 1
• Lipid management with statins for all patients with T1D or T2D and CKD 1
• Lifestyle modifications, such as diet, exercise, and smoking cessation, to reduce risk factors and improve overall health 1
• Regular risk factor reassessment (every 3-6 months) to monitor disease progression and adjust treatment as needed 1 SGLT2 inhibitors should be used for patients with CKD, regardless of diabetes status, as they have been shown to slow disease progression and reduce cardiovascular risk, and should be continued as long as tolerated, even if eGFR falls below 20 ml/min per 1.73 m², until kidney replacement therapy is initiated 1. Additional treatments, such as glucagon-like peptide-1 receptor agonists (GLP-1 RA) and nonsteroidal mineralocorticoid receptor antagonists (ns-MRA), may be considered for patients with high residual risks of kidney disease progression and cardiovascular events 1. Regular monitoring of kidney function, electrolytes, and complication markers is crucial, with referral to nephrology recommended at stage 3b (eGFR <45 ml/min) or earlier with rapid progression or 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.

Treatment of CKD with epoetin alfa (IV or SQ) involves:

• Initiating treatment when hemoglobin level is less than 10 g/dL
• Using the lowest dose sufficient to reduce the need for RBC transfusions
• Monitoring hemoglobin levels at least weekly until stable, then at least monthly
• Adjusting the dose based on hemoglobin level, with a target level not exceeding 11 g/dL
• Considering the risks of death, serious adverse cardiovascular reactions, and stroke when targeting a hemoglobin level greater than 11 g/dL 2 2

From the Research

Treatment of Chronic Kidney Disease (CKD)

The treatment of CKD involves a combination of lifestyle modifications, nutritional interventions, and medical therapies. 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.
• Lifestyle modifications: 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 3. Additionally, maintaining a healthy lifestyle, including a healthy diet, physical activity, weight management, abstaining from tobacco use, and limiting alcohol, is recommended 4.
• Medical therapies: Renin-angiotensin-aldosterone system (RAAS) blockade, sodium-glucose cotransporter-2 (SGLT2) inhibitors, pentoxifylline, and finerenone are approved for managing CKD 3. Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) have been shown to be effective in reducing the risk of cardiovascular events and delaying end-stage kidney disease (ESKD) in patients with CKD 5, 6.

Medications for CKD

Some of the medications used to treat CKD include:

• ACEIs: ACEIs have been shown to decrease the odds of kidney events, cardiovascular events, cardiovascular death, and all-cause death in non-dialysis CKD patients 5.
• ARBs: ARBs have been shown to decrease the odds of kidney events in non-dialysis CKD patients 5.
• SGLT2 inhibitors: SGLT2 inhibitors have been shown to be effective in managing CKD 3.
• Pentoxifylline: Pentoxifylline has been shown to be effective in managing CKD 3.
• Finerenone: Finerenone has been shown to be effective in managing CKD 3.

Lifestyle Modifications for CKD

Lifestyle modifications play a crucial role in the management of CKD. Some of the key lifestyle modifications include:

• Dietary changes: A low-protein diet, adherence to the alternate Mediterranean (aMed) diet, and Alternative Healthy Eating Index (AHEI)-2010 can slow the progression of CKD 3.
• Physical activity: Regular physical activity, such as walking, can slow the progression of CKD 3.
• Weight management: Maintaining a healthy weight can slow the progression of CKD 3.
• Smoking cessation: Smoking cessation can slow the progression of CKD 4.
• Limiting alcohol: Limiting alcohol consumption can slow the progression of CKD 4.