Table 2.

Gives more information on managing risk factors for CKD progression.

Blood pressure control: An ACEI or ARB should be the first-line agent for antihypertensive therapy for CKD patients and is recommended for patients with albuminuria regardless of the need for blood pressure control. Renin-angiotensin system inhibitors also have specific reno-protective effects in proteinuric non-diabetic chronic renal failure independent of blood pressure control, reducing proteinuria, and chronic kidney disease progression as defined by doubling baseline serum creatinine or development of end-stage kidney disease. The effect is most significant in those with higher levels of proteinuria.[22] The indications for starting renin-angiotensin system antagonists in chronic kidney disease are summarized below: Diabetes and ACR ≥ 3 mg/mmol. Hypertension and ACR ≥ 30 mg/mmol ACR ≥ 70 mg/mmol irrespective of hypertension or cardiovascular disease. ACR – Albumin to creatinine ratio. Blood pressure targets in chronic kidney disease are shown below: CKD: BP 120–139/<90 mm Hg. CKD and diabetes mellitus: BP 120–129/<80 mm Hg. CKD and ACR ≥ 70 mg/mmol: BP 120–129/<80 mm Hg. ACR = albumin to creatinine ratio, BP = blood pressure, CKD = chronic kidney disease. Potassium and eGFR should be measured before beginning renin-angiotensin system inhibitors and repeated 1–2 wk after starting renin-angiotensin system inhibitors and after each dose increase. Renin-angiotensin system antagonists should not be routinely given to people with chronic renal disease if the pretreatment potassium is more than 5.0 mmol/L and stopped if the potassium increases to ≥ 6.0 mmol/L and other drugs are known to promote hyperkalemia. Its blockade could lead to acute renal failure in conditions such as bilateral renal artery stenosis, where angiotensin is critical in preserving the intraglomerular pressure and GFR. Thus, checking serum creatinine and potassium about 1–2 weeks after starting or changing the dose of angiotensin-converting enzyme (ACE) inhibitor and angiotensin II receptor blocker (ARB) is recommended.

Diabetes mellitus: One in every 2 people who visit their primary care practice with type 2 diabetes will have CKD, diabetes is a significant risk factor for CKD, with up to 40% of CKD being caused by diabetes.[23] The presence of diabetes worsens the outcomes in all stages of CKD (cardiovascular outcomes, dialysis survival, and post-transplant survival).[23] The relatively strict control of blood glucose (hemoglobin A1c ≤ 7%) in type 1 and type 2 diabetes decreases the development of diabetic nephropathy and its progression. Diligent blood pressure control reduces kidney disease progression and cardiovascular morbidity and mortality among people with diabetes. Diabetes treatment targets: ≤7% (range 6.5–7.5); it needs individualization according to patient circumstances (e.g., disease duration, life expectancy, significant comorbidities, and established vascular complications). Interpret with caution if hemoglobin (Hb) is changing. The FDA revised its guidance for using metformin in CKD in 2016, recommending using eGFR rather than serum creatinine to guide treatment and expanding the pool of people with kidney disease for whom metformin treatment should be considered.[24] The revised FDA guidance states that: Metformin is not indicated in patients with an eGFR < 30 mL/min/1.73 m2. eGFR should be monitored when taking metformin. When the eGFR decreases to less than 45 mL/min/1.73 m2, the benefits and risks of continuing treatment should be reevaluated.[25] Patients with an eGFR of less than 45 mL/min/1.73 m2. Should not be given metformin. Metformin should be temporarily discontinued during or before iodinated contrast imaging examinations in patients with eGFR 30–60 mL/min/1.73 m2. SGLT2 inhibitors are recommended for people with stage 3 CKD or higher and type 2 diabetes, as they slow CKD progression and reduce heart failure risk independent of glucose management.[26] GLP-1 receptor agonists are suggested for cardiovascular risk reduction if such risk is a predominant problem. They reduce risks of cardiovascular disease events and hypoglycemia and appear to slow CKD progression, possibly.[27] Preferred antihypertensive therapy among people with diabetes with hypertension is with an ACEI or an ARB. ACEI or ARB therapy is also recommended for normotensive diabetics with microalbuminuria.

Cardiovascular disease: Cardiovascular disease is the leading cause of morbidity and mortality among patients with CKD. Recent studies have demonstrated that even early-stage chronic kidney disease constitutes a significant risk factor for cardiovascular events and death. Similarly, cardiovascular disease is a risk factor for the progression of CKD. Statins decrease the relative risk of cardiovascular events to a similar extent among people with and without CKD. However, the benefit is more significant in patients suffering from CKD because of the greater baseline risk for patients with chronic kidney disease. In addition to reducing cardiovascular risk, drugs like statins may have a role in preventing the progression of renal disease and reducing albuminuria. However, evidence for these outcomes is less robust. Based on the most recent KDIGO (Kidney Disease Improving Global Outcomes) guideline, statin use is: Recommended for all non-dialysis CKD patients ≥ 50 years of age, regardless of the stage of disease or the presence or absence of albuminuria. Suggested for non-dialysis or non-kidney transplant CKD patients who are 18 to 49 years of age and have an estimated risk of > 10% for a 10-year incidence of coronary death, or non-fatal myocardial infarction (includes any with coronary disease, diabetes mellitus, or ischemic stroke). Suggested for all kidney transplant patients, regardless of age. Suggested to continue in patients already receiving statins at dialysis initiation. Suggested not to be initiated in patients with dialysis-dependent CKD.[28]

Comorbidities: Patients suffering from CKD are at increased risk of developing several comorbidities, or co-existing health conditions, which can impact their overall health outcomes. Here are some of the most common comorbidities of CKD: Cardiovascular disease: CKD is strongly associated with an elevated risk of cardiovascular disease, including heart attacks, strokes, and heart failure. This is because the kidneys play a crucial role in regulating blood pressure and removing excess fluid and waste products from the body, and when they are not functioning correctly, this can strain the heart and blood vessels.[19] Diabetes: Diabetes is a leading cause of chronic kidney disease; the 2 conditions often co-exist. Individuals with diabetes are more likely to develop kidney disease, and people with CKD are more likely to develop diabetes. High blood sugar levels can damage the kidneys over time.[20] Anemia: Anemia is a common complication of CKD. It occurs when the kidneys can no longer produce enough erythropoietin hormone, which stimulates red blood cell production. This can result in fatigue, weakness, and shortness of breath.[21] Bone disease: CKD can also lead to renal osteodystrophy, a group of bone disorders resulting from the kidneys’ inability to regulate calcium and phosphorus levels in the blood. This can cause weakened bones, bone pain, and an increased risk of fractures.[22] Hyperkalemia: Hyperkalemia is a common complication of chronic kidney disease (CKD) and is considered a comorbidity of CKD. CKD can lead to a decreased ability of the kidneys to eliminate excess potassium from the body, resulting in high levels of potassium in the blood, known as hyperkalemia. Hyperkalemia can cause severe symptoms, including muscle weakness, heart palpitations, and cardiac arrest. Individuals with CKD must manage their potassium levels through diet, medications, and close monitoring by healthcare.[23] Metabolic acidosis: Metabolic acidosis is a common complication of chronic kidney disease (CKD) and is considered a comorbidity of CKD. The kidneys play a crucial role in maintaining the acid-base balance in the body by regulating the levels of bicarbonate, a base, and hydrogen ions, an acid. In CKD, the kidneys cannot excrete enough acid or produce enough bicarbonate, leading to a buildup of acid in the blood and decreased bicarbonate levels.[24] This results in a condition known as metabolic acidosis. Metabolic acidosis can cause various symptoms, including fatigue, shortness of breath, and confusion, and can lead to complications such as bone disease, muscle wasting, and kidney damage. Treatment for metabolic acidosis in CKD typically involves addressing the underlying cause, such as managing kidney function and providing bicarbonate supplements. Individuals with CKD must regularly monitor their acid-base balance to prevent complications associated with metabolic acidosis.[24] Dyslipidemia and hypercholesterolemia: Dyslipidemia is a condition characterized by abnormal levels of lipids (fats) in the blood, including high levels of LDL cholesterol (the “bad” cholesterol) and low levels of HDL cholesterol (the “good” cholesterol). In people with CKD, dyslipidemia is often present due to the decreased ability of the kidneys to remove lipids from the blood.[25] Hypercholesterolemia is a condition with an abnormally high cholesterol level in the blood, including high LDL cholesterol levels.[26] This can lead to atherosclerosis (narrowing the arteries due to the buildup of cholesterol and other substances), increasing the risk of heart disease and stroke. Both dyslipidemia and hypercholesterolemia are common in people with CKD. They can contribute to the increased risk of cardiovascular disease, a significant cause of morbidity and mortality in this population. Therefore, managing these conditions is integral to managing CKD.[26] Malnutrition: CKD can also lead to malnutrition, as the kidneys filter waste products from the blood and excrete them in the urine. When the kidneys are not functioning properly, waste products can build up in the blood, leading to a loss of appetite, nausea, and vomiting.[27] Depression and anxiety: People with CKD may also experience depression and anxiety, as the condition can significantly impact their quality of life. They may have to make significant lifestyle changes, such as following a restricted diet and undergoing regular dialysis treatments, which can be stressful and challenging to manage.[28] Overall, the comorbidities of CKD can significantly impact a patient’s health outcomes and quality of life. Therefore, it is essential to manage these conditions in addition to treating CKD itself.[29]

Dialysis and RRT options: Dialysis and renal replacement therapy (RRT) are 2 options for individuals with advanced stages of CKD. Dialysis is a medical procedure that helps filter waste and excess fluids from the blood when the kidneys can no longer perform this function adequately.[30] There are 2 types of dialysis: hemodialysis and peritoneal dialysis. Hemodialysis involves the use of a machine called a dialysis machine to filter the blood. During the procedure, the patient’s blood is drawn from an artery in the arm or leg and passed through a filter in the machine.[29] The vein returns the filtered blood to the patient’s body On the other hand, peritoneal dialysis involves using the lining of the patient’s abdomen as a filter. During the procedure, a catheter is inserted into the patient’s abdomen, and a special fluid called dialysate is infused into the abdomen. The dialysate pulls waste products and excess fluid from the blood into the abdominal cavity. After several hours, the dialysate is drained from the abdomen, taking the waste products and excess fluids.[28] Renal replacement therapy (RRT) is an option for individuals with advanced CKD who can no longer undergo dialysis. It involves using a kidney transplant to replace the patient’s damaged kidneys with a healthy donor kidney.[30] Both dialysis and RRT can significantly improve the quality of life for individuals with advanced CKD. However, they are not without risks and complications, and the decision to undergo either treatment should be made in consultation with a healthcare professional.[31]

Chronic kidney disease is an increasingly common clinical problem that raises a patient’s risk for developing several life-threatening medical conditions, including end-stage renal disease (ESRD) and cardiovascular disease. Appropriate treatment can delay or prevent these adverse outcomes.^[30,31] The direct management of chronic renal failure focuses on renin angiotensin aldosterone system antagonist (RAAS) and blood pressure control. Management also comprises optimal management of common comorbid conditions, e.g., diabetes, and addressing cardiovascular risk factors to decrease the risk for CVD. Also essential are patient education and a multidisciplinary approach to disease management that include dieticians, social workers, and other health care providers.^[31]