Prevent
Prevention of Kidney Disease Progression
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Prevention of Kidney Disease Progression
, Chronic Kidney Disease Prevention
See Also
Chronic Kidney Disease
End Stage Renal Disease
Acute Kidney Injury
Intravenous Contrast Related Acute Renal Failure
Drug Dosing in Chronic Kidney Disease
Nephrotoxic Drug
s
Renal Osteodystrophy
Risk Score for Prediction of Contrast-Induced Nephropathy After Percutaneous Coronary Intervention
Gadolinium-Associated Nephrogenic Systemic Fibrosis
(
Nephrogenic Fibrosing Dermopathy
)
Protocols
See
Drug Dosing in Chronic Kidney Disease
See
Renal Osteodystrophy
See
Nephrotoxic Drug
s
See
Intravenous Contrast Related Acute Renal Failure
See
Gadolinium-Associated Nephrogenic Systemic Fibrosis
(
Nephrogenic Fibrosing Dermopathy
)
Management
Nephrology
Consultation
indications
See
Chronic Kidney Disease
Management
Lifestyle, Diet and
Health Maintenance
Exercise
Moderate intensity aerobic
Exercise
150 minutes per week
Resistance Training
to prevent
Sarcopenia
Gene
ral Diet
Sodium
Restriction 2000 to 2300 mg/day
Plant-based diets with reduced animal
Protein
s are preferred
Maintain adequate daily oral hydration
Maintain adequate
Caloric Intake
per day and
In
Unintentional Weight Loss
, minimum intake: 35 Kcal/kg/day
Protein
restriction (Stage 4 to 5, controversial)
Low
Protein
diet
Serum Creatinine
2-4 (GFR 25-55): 0.8 g/kg/day
Serum Creatinine
>4 (GFR <25): 0.6 g/kg/day
Institute when
Serum Creatinine
>= 1.7
Appears to significantly benefit only patients with
Diabetes Mellitus
Contraindications to
Protein
restriction
Hemodialysis
Elderly
Malnutrition
Nephrotic Syndrome
(due to high
Protein
losses)
Habits
Tobacco Cessation
Vaccination
Influenza Vaccine
Tetanus Vaccine
Hepatitis B Vaccine
Covid-19 Vaccine
Recombinant
Shingles Vaccine
(
Shingrix
) if indicated
Pneumococcal Vaccine
(
Pneumovax
-23 and
Prevnar 13
)
Includes age 19 to 64 years with
ESRD
Cancer Screening is not recommended in
End Stage Renal Disease
(
ESRD
)
Life Expectancy
in
ESRD
is not sufficient to warrant longterm cancer screening
Management
Hypertension
and
Proteinuria
Gene
ral
Decreasing
Blood Pressure
and
Proteinuria
are the most important preventive measure in
Chronic Kidney Disease
Ambulatory or home
Blood Pressure Measurement
s are preferred for BP monitoring over
Hemodialysis
center BPs
Hypertension
is common in
ESRD
Hypertension
correlates with volume status
Modify hemodilaysis to maintain normovolemia
Goals of therapy
Decrease
Proteinuria
by 50%
Decrease
Blood Pressure
Goal BP in
Chronic Kidney Disease
is controversial
KDIGO (2021): SBP <120 mmHg
VA/DOD and JNC-8: BP<140/90 mmHg
Prior guidelines recommended goal BP <130/80 mmHg
References
Arguedas (2009) Cochrane Database Syst Rev CD004349
(2004) Am J Kidney Dis 43(5 suppl 1): S1-S290 [PubMed]
Gene
ral Measures
Limit
Dietary Sodium
intake (<2300 mg/day)
Lowers
Blood Pressure
and decreases albuminuria
McMahon (2021) Cochrane Database Syst Rev (6):CD010070 [PubMed]
Control
Hypertension
and
Proteinuria
with
ACE Inhibitor
ACE Inhibitor
(or
Angiotensin Receptor Blocker
) should be first
Antihypertensive
used
Efficacious in
Diabetic Nephropathy
Efficacious in non-diabetic renal disease
Jafar (2001) Ann Intern Med 135:73-87 [PubMed]
Indication
Hypertension
(
Blood Pressure
>130/80 mmHg)
Proteinuria
Diabetes Mellitus
Microalbuminuria
in
Diabetes Mellitus
(
Diabetic Nephropathy
)
Non-Diabetic
Proteinuria
on
Urinalysis
(1+
Protein
on
Urinalysis
or >1 gram per day)
Random
Protein
to
Creatinine
ratio >200 mg
Protein
/g
Creatinine
Observe for
Hyperkalemia
Avoid with
Potassium
sparing
Diuretic
Avoid with
Potassium Supplementation
Management with adverse effects
Orthostasis
: Maximize clear fluid intake
Adjunctive
Antihypertensive
agents
Step 1:
ACE Inhibitor
or
Angiotensin Receptor Blocker
See above
Step 2:
Non-Dihydropyridine Calcium Channel Blocker
Diltiazem
or
Verapamil
Step 3:
Hydrochlorothiazide
(or other
Thiazide Diuretic
)
Use
Furosemide
(or other
Loop Diuretic
) instead if
Creatinine Clearance
<30 ml/min
Step 4:
Beta Blocker
Use with caution due to possible adverse outcomes (including third degree
AV Block
)
Management
Comorbid Conditions
Diabetes Mellitus
See
Diabetic Nephropathy
Maximize glycemic control in
Diabetes Mellitus
Hemoglobin A1C
<7% best reduces
Diabetic Nephropathy
risk
Precaution: ACCORD Study found higher overall mortality with intensive glycemic control in
Type II Diabetes
Goal <8% is also effective in preventing
Diabetic Nephropathy
progression with fewer adverse effects
Gerstein (2008) N Engl J Med 358(24): 2545-59 [PubMed]
Maintain careful
Blood Glucose Monitoring
in
ESRD
(higher risk for
Hypoglycemia
)
Hemodialysis
typically helps improve
Hyperglycemia
management
Hemoglobin A1C
may be inaccurate in
ESRD
(esp. on
Hemodialysis
)
Glucose
monitoring logs are preferred
Medications preferred when GFR>30 ml/min/1.73m2 (most are contraindicated for GFR<20 to 30 ml/min)
SGLT2 Inhibitor
s
Metformin
GLP1 Agonist
Insulin
is preferred in
ESRD
or GFR <20 to 30 ml/min/1.73m2
Many other diabetic medications (e.g.
Metformin
) are contraindicated in low GFR
Alternatives include
Glipizide
(but risk of
Hypoglycemia
) and
Repaglinide
Other measures to slow
Diabetic Nephropathy
progression
Finerenone
(
Kerendia
)
Coronary Artery Disease
High
Incidence
of comorbidity
Most
ESRD
patients die of
Coronary Artery Disease
before
Dialysis
Gene
ral measures
Aspirin
81 mg orally daily
Statin
for most patients
Control
Hypertension
CAD primary prevention in
Chronic Kidney Disease
for those WITHOUT
Coronary Artery Disease
Antiplatelet Therapy
(e.g.
Aspirin
) reduces the risk of MI (NNT 125) but increases the risk of major bleed (NNH 100)
Natale (2022) Cochrane Database Syst Rev (2): CD008834 [PubMed]
Hyperlipidemia
Statin
drugs are preferred
Goal
LDL Cholesterol
<100 mg/dl
Goal
Triglyceride
s <200 mg/dl
Lipid
lowering therapy beyond age 80 does not appear to alter all-cause mortality
Petersen (2010) Age Ageing 39(6): 674-80 [PubMed]
Avoid additional
Kidney
injury
Early recognition and treatment of UTI
Tobacco Cessation
Avoid
Rhabdomyolysis Causes
(esp.
Dehydration
)
Maintain hemodynamic stability in
Acute Renal Failure
Avoid volume depletion
Maintain mean arterial pressure >65 mmHg
Vasopressor
s may be required
Avoid renal dose
Dopamine
due toworse outcomes
Manage
Nephrotoxicity Risk
s and contraindicated medications at low GFR (<30 ml/min)
Avoid
Nephrotoxic Drug
s
Measure drug levels of nephrotoxic medications
Limit radiologic
Contrast Material
to low density
See
Intravenous Contrast Related Acute Renal Failure
See
Gadolinium-Associated Nephrogenic Systemic Fibrosis
(
Nephrogenic Fibrosing Dermopathy
)
See
Risk Score for Prediction of Contrast-Induced Nephropathy After Percutaneous Coronary Intervention
Prefer lowest volume of lowest osmolar
Contrast Material
Optimize hydration status (e.g.
Isotonic Saline
) prior to
Contrast Material
and consider
N-Acetylcysteine
Other medication limitations for GFR <20 to 30 ml/min
Avoid
Metformin
and
Flozins
(
SGLT2 Inhibitor
s) in
Type II Diabetes
Avoid
Bisphosphonates
Avoid
Direct Oral Anticoagulant
s
Avoid
NSAID
s
For
Bowel Preparation
, use
Polyethylene Glycol
(PEG) instead of
Magnesium
or
Phosphorus
preparations
Chemotherapy
with risk of
Tumor Lysis Syndrome
(prevent
Uric Acid
nephropathy)
Pre-hydrate prior to
Chemotherapy
Consider
Allopurinol
prior to
Chemotherapy
Hepatic failure (
Cirrhosis
)
Early recognition and treatment of bleeding,
Ascites
and
Spontaneous Bacterial Peritonitis
Replace albumin as needed
Management
End Stage Renal Disease
Complications
See
End Stage Renal Disease
Careful fluid balance (avoid
Fluid Overload
as well as
Dehydration
)
Hyperkalemia
Limit
Dietary Potassium
intake to 70 meq/day
Metabolic Acidosis
Treat if serum bicarbonate <20
Hyperphosphatemia
See
Renal Osteodystrophy
Causes Osteitis fibrosa cystica (poor bone strength)
Results from
Hyperparathyroidism
Management
Restrict dietary phosphate (limit to 1200 mg/day)
Avoid soda
Avoid nuts, peas or beans
Avoid dairy products
Medications
See
Calcium and Phophorus Metabolism in Chronic Kidney Disease
Calcium Supplementation
(maximum 1.2 to 2.0 grams daily)
Phosphate-binding
Calcium Carbonate
or acetate
Sevelamer
hydrochloride or carbonate
Vitamin D Supplement
ation (critical!)
Correct acidosis
Anemia
(
Hemoglobin
<11 grams per dl)
Iron
supplement indicated for
Ferritin
<10 ng/ml
Erythropoetin or
Aranesp
indications
Anemia
dependent
Angina
Hemoglobin
decline requires transfusion
Hemoglobin
<10 grams/dl or
Hematocrit
<30-32
Use goal >9 grams/dl in comorbid cancer
Avoid increasing
Hemoglobin
>11 g/dl (higher morbidity and mortality)
References
(2007) Am J Kidney Dis 50(3): 471-530 [PubMed]
FDA EPO agent recommendations
http://www.fda.gov/Drugs/DrugSafety/ucm259639.htm
Osteoporosis
Control
Calcium
and
Phosphorus
Control
Parathyroid Hormone
Use
Bisphosphonates
only with caution
Consider nephrology
Consultation
Do not use for GFR <30-40 ml/min
Only use for strong indications
Fracture
s or bone loss
High bone turnover by bone biopsy
Controlled PTH,
Calcium
and
Phosphorus
References
(2002) Am J
Kidney
Dis 39:S1
Goodbred (2023) Am Fam Physician 108(6): 554-61 [PubMed]
Rivera (2012) Am Fam Physician 86(8): 749-54 [PubMed]
Snively (2004) Am Fam Physician 70:1921-30 [PubMed]
Stigant (2003) CMAJ 168:1553-60 [PubMed]
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