Management of Patients with Chronic Kidney Disease
Chronic kidney disease is a damaged kidney or a decreased glomerular filtration rate; it includes all levels of decreased kidney function. A decrease in kidney function is either mild, moderate, or severe. Notably, the elderly are more affected by chronic kidney diseases than younger patients. Nonetheless, chronic kidney disease is a global problem with high prevalence and incidence, hence the need for proper treatment and management (Kovesdy, 2022). Adequate treatment and management reduce the risk of end-stage renal disease and cardiovascular disease. An early diagnosis, treatment, and management are crucial for preventing chronic kidney disease and treating the underlying disorder. Treatment and management of chronic kidney disease aim to prevent disease progression, slow disease progression, treat the underlying disorder, and provide long-term renal replacement therapy (Vaidya & Aeddula, 2022).
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Management of chronic kidney disease focuses on stopping or slowing disease progression through blood pressure control, treatment of underlying causes, blood glucose level control, treatment of hyperlipidemia, and avoiding nephrotoxins (Vaidya & Aeddula, 2022). To prevent nephrotoxicity, NSAIDs, aminoglycosides, and other nephrotoxic drugs are controlled in chronic disease patients. Thyroid hormone replacement therapy using L-thyroxine prevents and slows progression to end-stage renal disease. Angiotensin receptor blockers such as losartan are prescribed for diabetic kidney disease and proteinuria to control blood pressure. Angiotensin-converting enzyme inhibitors are prescribed in proteinuria.
Pathologic manifestations of chronic kidney disease include anemia, hyperparathyroidism, metabolic acidosis, volume overload, uremic manifestations, growth failure in children, hyperphosphatemia, cardiovascular complications, and hypocalcemia (Vaidya & Aeddula, 2022). Patients with non-hemodialysis dependent chronic kidney disease with a hemoglobin A1c of more than 9% lead to worse clinical outcomes, while patients with lower HbA1c levels have higher mortality rates. Anemia is treated using erythropoietin to ensure a hemoglobin level of 10 to 12 g/dL, ferritin at 200 to 500 ng/mL, and an iron saturation of 30% to 50%. Patients with chronic kidney disease and diabetes mellitus require intensive control of blood glucose levels and HbA1c levels. Hyperphosphatemia, hypocalcemia, and hyperparathyroidism are mineral and bone disorders that are pathologic manifestations of chronic kidney disease. Treatment aims to decrease phosphorus levels, prevent osteoporosis, decrease parathyroid hormone levels, and maintain calcium levels. Hyperphosphatemia is treated using dietary changes and phosphate binders. Dietary adjustments aim to restrict dietary phosphate intake in chronic kidney disease patients. Phosphate binders such as calcium acetate decrease phosphorus levels. Hypocalcemia is treated using calcitriol and calcium supplements, while hyperparathyroidism is treated using vitamin D analogs and calcitriol.
Metabolic acidosis is a pathologic manifestation of chronic kidney disease. Treatment and management of metabolic acidosis impact bone metabolism and protein in chronic kidney disease patients. Patients are managed using alkali therapy to ensure the serum bicarbonate concentration is higher than 22 mEq/L. Bicarbonate supplementation of about 6g/day slows the decline of renal function and the progression of chronic kidney disease (Vaidya & Aeddula, 2022). Cardiovascular complications are a pathologic manifestation of chronic kidney disease. Cardiovascular complications are prevented and treated using statins and non-vitamin K oral anticoagulants (NOACs). Patients with a GFR lower than 60Ml/min/1.73m who are not on kidney transplant or long-term dialysis are treated with statins and ezetimibe. Statins and ezetimibe are patients on long-term dialysis for chronic kidney disease. Patients already on statin therapy before dialysis should continue with their statins during dialysis. Statins lower the risk of coronary events. NOACs are indicated for venous thromboembolism, atrial fibrillation, and dialysis access thrombosis prophylaxis.
Treatment and management of chronic kidney disease focus on renal replacement therapy. Patients who require renal replacement therapy mainly present with encephalopathy, severe metabolic acidosis, pericarditis, hyperkalemia, peripheral neuropathy, intractable volume overload, intractable gastrointestinal symptoms, growth failure, and malnutrition (Vaidya & Aeddula, 2022). Asymptomatic adults with a GFR of 5 to 9 Ml/min/1.73 m are scheduled for renal replacement therapy without considering other comorbidities and the underlying cause of the chronic kidney disease. Dietary management plays a critical role in treating and managing chronic kidney disease. Nutrition recommends protein, salt, potassium, sodium, and water restriction in chronic kidney disease patients. Adult patients approaching CKD stage 5 require a low-protein diet to slow down the onset of uremic symptoms and delay a decrease in GFR. Malnutrition patients should not participate in an overly aggressive protein diet restriction to prevent morbidity and mortality. Salt restriction of less than 5 to 6g daily slows down diabetes in chronic kidney disease and lowers blood pressure.
Lifestyle modifications are non-pharmacological management of chronic kidney disease. Patients are advised on the benefits of smoking cessation to prevent end-stage renal disease. Exercise professionals prescribe individualized exercises for chronic disease patients. Patients on dialysis are advised on aerobic exercises to improve their quality of life and physical fitness. Patients suffering from early chronic kidney disease take part in resistance training. Dose adjustments and modifications are crucial for medications prescribed to chronic kidney disease patients (Kyriakopoulos & Gupta, 2022). Clinical pharmacists assist in designing patient-specific dosing regimens. Chronic kidney disease patients require long-term monitoring and multidisciplinary management. Consultations involve renal dietitians, nephrologists, surgeons, renal nurses, renal clinical pharmacists, social workers, primary care physicians, and transplant centers. Patients are frequently monitored for obstructive sleep apnea.
References
Kovesdy C. P. (2022). Epidemiology of chronic kidney disease: an update 2022. Kidney International Supplements, 12(1), 7–11. https://doi.org/10.1016/j.kisu.2021.11.003
Kyriakopoulos C., & Gupta, V. (2021). Renal Failure Drug Dose Adjustments. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK560512/
Vaidya, S.R., & Aeddula, N.R. (2021). Chronic Renal Failure. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK535404/
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