Skip to main content
NCBI home page
Canadian Family Physician logoLink to Canadian Family Physician
. 1999 Apr;45:977–984.

Managing progressive renal disease before dialysis.

B J Barrett 1
PMCID: PMC2328320  PMID: 10216796

Abstract

OBJECTIVE: To enhance awareness of issues affecting patients with chronic renal failure and to provide guidance for primary care practitioners managing such patients. QUALITY OF EVIDENCE: Randomized trials establish the efficacy of blood pressure control and angiotensin-converting enzyme (ACE) inhibition in slowing the progression of chronic renal disease. Some randomized trials and many prospective studies address management of anemia, hyperparathyroidism, and multidisciplinary predialysis care. The benefits of lipid lowering are suggested by randomized trials among patients without renal disease. MAIN MESSAGE: Progression of renal failure, particularly in patients with proteinuria, can be slowed by lowering blood pressure. Angiotensin-converting enzyme inhibitors are more beneficial than other antihypertensives in this situation. Partial correction of anemia with iron, erythropoietin, or androgens can improve quality of life and potentially prevent cardiac disease. Renal bone disease and secondary hyperparathyroidism can be prevented in part by early dietary phosphate restriction, use of calcium-containing phosphate binders, and activated vitamin D. Correction of acidosis could improve protein metabolism and bone and cardiovascular health. Treatment of hyperlipidemia might reduce cardiovascular disease. Early involvement of a nephrology-based multidisciplinary team has the potential to reduce morbidity and costs, enhance patients' knowledge of their condition, and prolong the period before dialysis is required. CONCLUSIONS: Care of patients with progressive renal failure is complex and requires attention to detail. Family doctors play a vital role in these efforts and should be involved in all aspects of care.

Full text

PDF
977

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Apperloo A. J., de Zeeuw D., de Jong P. E. A short-term antihypertensive treatment-induced fall in glomerular filtration rate predicts long-term stability of renal function. Kidney Int. 1997 Mar;51(3):793–797. doi: 10.1038/ki.1997.111. [DOI] [PubMed] [Google Scholar]
  2. Aurell M., Bengtsson C., Björck S. Enalapril versus metoprolol in primary hypertension--effects on the glomerular filtration rate. Nephrol Dial Transplant. 1997 Nov;12(11):2289–2294. doi: 10.1093/ndt/12.11.2289. [DOI] [PubMed] [Google Scholar]
  3. Bannister K. M., Weaver A., Clarkson A. R., Woodroffe A. J. Effect of angiotensin-converting enzyme and calcium channel inhibition on progression of IgA nephropathy. Contrib Nephrol. 1995;111:184–193. doi: 10.1159/000423895. [DOI] [PubMed] [Google Scholar]
  4. Barrett B. J., Parfrey P. S., Morgan J., Barré P., Fine A., Goldstein M. B., Handa S. P., Jindal K. K., Kjellstrand C. M., Levin A. Prediction of early death in end-stage renal disease patients starting dialysis. Am J Kidney Dis. 1997 Feb;29(2):214–222. doi: 10.1016/s0272-6386(97)90032-9. [DOI] [PubMed] [Google Scholar]
  5. Binik Y. M., Devins G. M., Barre P. E., Guttmann R. D., Hollomby D. J., Mandin H., Paul L. C., Hons R. B., Burgess E. D. Live and learn: patient education delays the need to initiate renal replacement therapy in end-stage renal disease. J Nerv Ment Dis. 1993 Jun;181(6):371–376. doi: 10.1097/00005053-199306000-00006. [DOI] [PubMed] [Google Scholar]
  6. Blantz R. C., Gabbai F., Gushwa L. C., Wilson C. B. The influence of concomitant experimental hypertension and glomerulonephritis. Kidney Int. 1987 Nov;32(5):652–663. doi: 10.1038/ki.1987.257. [DOI] [PubMed] [Google Scholar]
  7. Buckalew V. M., Jr, Berg R. L., Wang S. R., Porush J. G., Rauch S., Schulman G. Prevalence of hypertension in 1,795 subjects with chronic renal disease: the modification of diet in renal disease study baseline cohort. Modification of Diet in Renal Disease Study Group. Am J Kidney Dis. 1996 Dec;28(6):811–821. doi: 10.1016/s0272-6386(96)90380-7. [DOI] [PubMed] [Google Scholar]
  8. Epstein M. Calcium antagonists and the progression of chronic renal failure. Curr Opin Nephrol Hypertens. 1998 Mar;7(2):171–176. doi: 10.1097/00041552-199803000-00005. [DOI] [PubMed] [Google Scholar]
  9. Erlichman M., Holohan T. V. Bone densitometry: patients with end-stage renal disease. Health Technol Assess (Rockv) 1996 Mar;(8):1–27. [PubMed] [Google Scholar]
  10. Estacio R. O., Jeffers B. W., Hiatt W. R., Biggerstaff S. L., Gifford N., Schrier R. W. The effect of nisoldipine as compared with enalapril on cardiovascular outcomes in patients with non-insulin-dependent diabetes and hypertension. N Engl J Med. 1998 Mar 5;338(10):645–652. doi: 10.1056/NEJM199803053381003. [DOI] [PubMed] [Google Scholar]
  11. Giatras I., Lau J., Levey A. S. Effect of angiotensin-converting enzyme inhibitors on the progression of nondiabetic renal disease: a meta-analysis of randomized trials. Angiotensin-Converting-Enzyme Inhibition and Progressive Renal Disease Study Group. Ann Intern Med. 1997 Sep 1;127(5):337–345. doi: 10.7326/0003-4819-127-5-199709010-00001. [DOI] [PubMed] [Google Scholar]
  12. Hamdy N. A., Kanis J. A., Beneton M. N., Brown C. B., Juttmann J. R., Jordans J. G., Josse S., Meyrier A., Lins R. L., Fairey I. T. Effect of alfacalcidol on natural course of renal bone disease in mild to moderate renal failure. BMJ. 1995 Feb 11;310(6976):358–363. doi: 10.1136/bmj.310.6976.358. [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Hansson L., Zanchetti A., Carruthers S. G., Dahlöf B., Elmfeldt D., Julius S., Ménard J., Rahn K. H., Wedel H., Westerling S. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. HOT Study Group. Lancet. 1998 Jun 13;351(9118):1755–1762. doi: 10.1016/s0140-6736(98)04311-6. [DOI] [PubMed] [Google Scholar]
  14. Ismail N. Use of erythropoietin, active vitamin D3 metabolites, and alkali agents in predialysis patients. Semin Nephrol. 1997 Jul;17(4):270–284. [PubMed] [Google Scholar]
  15. Khan I. H., Catto G. R., Edward N., MacLeod A. M. Chronic renal failure: factors influencing nephrology referral. QJM. 1994 Sep;87(9):559–564. [PubMed] [Google Scholar]
  16. Klahr S. Is there still a role for a diet very low in protein, with or without supplements, in the management of patients with end-stage renal failure? Curr Opin Nephrol Hypertens. 1996 Jul;5(4):384–387. doi: 10.1097/00041552-199607000-00017. [DOI] [PubMed] [Google Scholar]
  17. Klahr S., Levey A. S., Beck G. J., Caggiula A. W., Hunsicker L., Kusek J. W., Striker G. The effects of dietary protein restriction and blood-pressure control on the progression of chronic renal disease. Modification of Diet in Renal Disease Study Group. N Engl J Med. 1994 Mar 31;330(13):877–884. doi: 10.1056/NEJM199403313301301. [DOI] [PubMed] [Google Scholar]
  18. Klahr S., Schreiner G., Ichikawa I. The progression of renal disease. N Engl J Med. 1988 Jun 23;318(25):1657–1666. doi: 10.1056/NEJM198806233182505. [DOI] [PubMed] [Google Scholar]
  19. Lazarus J. M., Bourgoignie J. J., Buckalew V. M., Greene T., Levey A. S., Milas N. C., Paranandi L., Peterson J. C., Porush J. G., Rauch S. Achievement and safety of a low blood pressure goal in chronic renal disease. The Modification of Diet in Renal Disease Study Group. Hypertension. 1997 Feb;29(2):641–650. doi: 10.1161/01.hyp.29.2.641. [DOI] [PubMed] [Google Scholar]
  20. Levin A., Lewis M., Mortiboy P., Faber S., Hare I., Porter E. C., Mendelssohn D. C. Multidisciplinary predialysis programs: quantification and limitations of their impact on patient outcomes in two Canadian settings. Am J Kidney Dis. 1997 Apr;29(4):533–540. doi: 10.1016/s0272-6386(97)90334-6. [DOI] [PubMed] [Google Scholar]
  21. Levin A., Singer J., Thompson C. R., Ross H., Lewis M. Prevalent left ventricular hypertrophy in the predialysis population: identifying opportunities for intervention. Am J Kidney Dis. 1996 Mar;27(3):347–354. doi: 10.1016/s0272-6386(96)90357-1. [DOI] [PubMed] [Google Scholar]
  22. Lewis E. J., Hunsicker L. G., Bain R. P., Rohde R. D. The effect of angiotensin-converting-enzyme inhibition on diabetic nephropathy. The Collaborative Study Group. N Engl J Med. 1993 Nov 11;329(20):1456–1462. doi: 10.1056/NEJM199311113292004. [DOI] [PubMed] [Google Scholar]
  23. Locatelli F., Marcelli D., Comelli M., Alberti D., Graziani G., Buccianti G., Redaelli B., Giangrande A. Proteinuria and blood pressure as causal components of progression to end-stage renal failure. Northern Italian Cooperative Study Group. Nephrol Dial Transplant. 1996 Mar;11(3):461–467. doi: 10.1093/ndt/11.3.461. [DOI] [PubMed] [Google Scholar]
  24. Massy Z. A., Kasiske B. L. Hyperlipidemia and its management in renal disease. Curr Opin Nephrol Hypertens. 1996 Mar;5(2):141–146. doi: 10.1097/00041552-199603000-00007. [DOI] [PubMed] [Google Scholar]
  25. Massy Z. A., Ma J. Z., Louis T. A., Kasiske B. L. Lipid-lowering therapy in patients with renal disease. Kidney Int. 1995 Jul;48(1):188–198. doi: 10.1038/ki.1995.284. [DOI] [PubMed] [Google Scholar]
  26. Mendelssohn D. C., Chery A. Dialysis utilization in the Toronto region from 1981 to 1992. Toronto Region Dialysis Committee. CMAJ. 1994 Apr 1;150(7):1099–1105. [PMC free article] [PubMed] [Google Scholar]
  27. Navis G., Faber H. J., de Zeeuw D., de Jong P. E. ACE inhibitors and the kidney. A risk-benefit assessment. Drug Saf. 1996 Sep;15(3):200–211. doi: 10.2165/00002018-199615030-00005. [DOI] [PubMed] [Google Scholar]
  28. Navis G., de Zeeuw D. Titrating for antiproteinuric effect: the clue to renoprotection? J Hum Hypertens. 1996 Oct;10(10):669–673. [PubMed] [Google Scholar]
  29. Parving H. H., Andersen A. R., Smidt U. M., Hommel E., Mathiesen E. R., Svendsen P. A. Effect of antihypertensive treatment on kidney function in diabetic nephropathy. Br Med J (Clin Res Ed) 1987 Jun 6;294(6585):1443–1447. doi: 10.1136/bmj.294.6585.1443. [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Peterson J. C., Adler S., Burkart J. M., Greene T., Hebert L. A., Hunsicker L. G., King A. J., Klahr S., Massry S. G., Seifter J. L. Blood pressure control, proteinuria, and the progression of renal disease. The Modification of Diet in Renal Disease Study. Ann Intern Med. 1995 Nov 15;123(10):754–762. doi: 10.7326/0003-4819-123-10-199511150-00003. [DOI] [PubMed] [Google Scholar]
  31. Portolés J., Torralbo A., Martin P., Rodrigo J., Herrero J. A., Barrientos A. Cardiovascular effects of recombinant human erythropoietin in predialysis patients. Am J Kidney Dis. 1997 Apr;29(4):541–548. doi: 10.1016/s0272-6386(97)90335-8. [DOI] [PubMed] [Google Scholar]
  32. Rasgon S., Schwankovsky L., James-Rogers A., Widrow L., Glick J., Butts E. An intervention for employment maintenance among blue-collar workers with end-stage renal disease. Am J Kidney Dis. 1993 Sep;22(3):403–412. doi: 10.1016/s0272-6386(12)70143-9. [DOI] [PubMed] [Google Scholar]
  33. Ravid M., Brosh D., Levi Z., Bar-Dayan Y., Ravid D., Rachmani R. Use of enalapril to attenuate decline in renal function in normotensive, normoalbuminuric patients with type 2 diabetes mellitus. A randomized, controlled trial. Ann Intern Med. 1998 Jun 15;128(12 Pt 1):982–988. doi: 10.7326/0003-4819-128-12_part_1-199806150-00004. [DOI] [PubMed] [Google Scholar]
  34. Ravid M., Lang R., Rachmani R., Lishner M. Long-term renoprotective effect of angiotensin-converting enzyme inhibition in non-insulin-dependent diabetes mellitus. A 7-year follow-up study. Arch Intern Med. 1996 Feb 12;156(3):286–289. [PubMed] [Google Scholar]
  35. Revicki D. A., Brown R. E., Feeny D. H., Henry D., Teehan B. P., Rudnick M. R., Benz R. L. Health-related quality of life associated with recombinant human erythropoietin therapy for predialysis chronic renal disease patients. Am J Kidney Dis. 1995 Apr;25(4):548–554. doi: 10.1016/0272-6386(95)90122-1. [DOI] [PubMed] [Google Scholar]
  36. Samuelsson O., Mulec H., Knight-Gibson C., Attman P. O., Kron B., Larsson R., Weiss L., Wedel H., Alaupovic P. Lipoprotein abnormalities are associated with increased rate of progression of human chronic renal insufficiency. Nephrol Dial Transplant. 1997 Sep;12(9):1908–1915. doi: 10.1093/ndt/12.9.1908. [DOI] [PubMed] [Google Scholar]
  37. Shiigai T., Hattori K., Iwamoto H., Owada A. Long-term enalapril therapy in patients with chronic renal failure on a low-protein diet. A prospective randomized comparison with metoprolol. Nephron. 1998;79(2):148–153. doi: 10.1159/000045017. [DOI] [PubMed] [Google Scholar]
  38. Tatti P., Pahor M., Byington R. P., Di Mauro P., Guarisco R., Strollo G., Strollo F. Outcome results of the Fosinopril Versus Amlodipine Cardiovascular Events Randomized Trial (FACET) in patients with hypertension and NIDDM. Diabetes Care. 1998 Apr;21(4):597–603. doi: 10.2337/diacare.21.4.597. [DOI] [PubMed] [Google Scholar]
  39. Teruel J. L., Aguilera A., Marcen R., Navarro Antolin J., Garcia Otero G., Ortuño J. Androgen therapy for anaemia of chronic renal failure. Indications in the erythropoietin era. Scand J Urol Nephrol. 1996 Oct;30(5):403–408. doi: 10.3109/00365599609181318. [DOI] [PubMed] [Google Scholar]
  40. Whelton P. K., He J., Perneger T. V., Klag M. J. Kidney damage in 'benign' essential hypertension. Curr Opin Nephrol Hypertens. 1997 Mar;6(2):177–183. doi: 10.1097/00041552-199703000-00012. [DOI] [PubMed] [Google Scholar]
  41. Yagil Y. Proposed therapeutic algorithm for the treatment of anemia of chronic renal failure in pre-dialysis patients with low dose once weekly subcutaneous r-HuEPO. Multicenter Study Group, Israel. Isr J Med Sci. 1997 Jan;33(1):36–44. [PubMed] [Google Scholar]
  42. Zucchelli P., Zuccalà A. Blood pressure control effects on the progression of chronic renal failure. Ren Fail. 1993;15(3):339–342. doi: 10.3109/08860229309054941. [DOI] [PubMed] [Google Scholar]
  43. ter Wee P. M., De Micheli A. G., Epstein M. Effects of calcium antagonists on renal hemodynamics and progression of nondiabetic chronic renal disease. Arch Intern Med. 1994 Jun 13;154(11):1185–1202. doi: 10.1001/archinte.154.11.1185. [DOI] [PubMed] [Google Scholar]

Articles from Canadian Family Physician are provided here courtesy of College of Family Physicians of Canada

RESOURCES