Chronic Kidney Disease : Treatment

Importance and Goals

The three treatment options for CKD are medical management, dialysis or transplant.

• All patients with CKD are treated initially by medical management (medicine, dietary advice and monitoring).
• Severe damage in CKD (ESKD) requires kidney replacement by dialysis or transplant.

Why is medical management very important in CKD?

There is no cure for CKD. Advanced CKD needs dialysis or kidney transplant to maintain life. Because of the high cost and problems of availability, in India only 5 -10% of kidney patients get treatment like dialysis and kidney transplant, while the rest die without getting any definitive therapy. Therefore, early detection and meticulous conservative medical management is the only feasible and less expensive way to manage CKD and delay the need for dialysis or transplant.

Initiation of proper therapy at early stages of CKD is most rewarding. Most patients are asymptomatic or feel very well with proper therapy in early stages. Because of the absence of symptoms many patients and their families fail to recognize the seriousness of the disease and discontinue medicine and dietary restrictions. Discontinuation of therapy may lead to rapid worsening of kidney function requiring expensive dialysis or kidney transplantation.

In CKD with early medical management patients can live a long life.

In CKD with early medical management patients can live a long life.

What are the goals of medical management in CKD?

CKD is a progressively deteriorating condition with no cure. The aims of medical management are to:

1. Slow down the progression of the disease.
2. Treat underlying causes and contributing factors.
3. Relieve symptoms and treat complications of the disease.
4. Reduce the risk of developing cardiovascular disease.
5. Delay the need for dialysis or transplant.

What are the treatment strategies in different stages of CKD?

Treatment strategies and recommended actions in different stages of chronic kidney disease are summarized in this table.

Nine steps action plan

Identifying and treating these underlying primary conditions may help prevent, delay or reverse the progression of CKD.

• Diabetes mellitus and hypertension.
• Urinary tract infection or obstruction.
• Glomerulonephritis, renovascular disease, analgesic nephropathy etc.

Your doctor may prescribe important and effective measures to slow down the progression of CKD such as:

• Strict blood pressure control and ACE inhibitor or angiotensin II receptor–blocker therapy.
• Protein restriction.
• Lipid lowering therapy.
• Correction of anemia.

• Water pill (diuretics) to increase volume of urine and reduce swelling.
• Drugs to control nausea, vomiting and gastric discomforts.
• Supplementation of calcium, phosphate binders, active form of Vitamin D and other drugs to prevent and correct CKD related bone disease.
• Correction of low hemoglobin (anemia) with iron, vitamins and erythropoietin injections.
• Prevention of cardiovascular events. Start daily aspirin advised unless contraindicated.

Search and treat reversible factors that may have aggravated or exacerbated the degree of kidney failure. By correction of reversible factors kidney failure may improve, and kidney function may return to stable base level of function. The common reversible causes are:

• Volume depletion.
• Kidney failure due to drugs (non steroidal anti-inflammatory drugs or NSAIDs, contrast agents, aminoglycosides antibiotics).
• Infection and congestive heart failure.

Complications of CKD require early diagnosis and immediate treatment. The common complications which need attention are severe fluid overload, high potassium level in blood (potassium > 6.0 mEq/L), and severe ill effects of advanced kidney failure on heart, brain and lungs.

These measures are important in reducing overall risk:

• Stop smoking.
• Maintain healthy weight, exercise regularly and remain physically active on a regular basis.
• Limit alcohol intake.
• Follow a healthy eating plan and reduce dietary salt intake.
• Medications should be taken as directed by the doctor. They may be adjusted according to the severity of the kidney damage.
• Regular follow up and treatment as directed by a nephrologist.

Depending on the type and severity of kidney disease, dietary restrictions are needed in CKD (discussed in detail in Chapter 25).

• Salt (sodium): To control high blood pressure and swelling, salt restriction is advised. Salt restriction includes: not adding salt to foods at the table and avoiding salt rich food such as fast food, papad, pickles and minimizing the use of most canned foods.
• Fluid intake:Decreased urine volume in CKD patients can cause swelling and in severe cases even breathlessness. Therefore, fluid restriction is advised for all CKD patients with swelling.
• Potassium Blood potassium levels usually rise in CKD patients. This can have life-threatening effects on the heart activity. To prevent this, intake of potassium-rich foods (such as dry fruit, coconut water, potatoes, oranges, bananas, tomatoes etc.) should be restricted as advised by a doctor.
• Protein: Patients with CKD should avoid high-protein diets which may accelerate the rate of kidney damage.

• Protect veins of the non-dominant forearm as soon as CKD is diagnosed.
• Use of the veins of this arm should be avoided for blood collection or IV infusions.
• As kidney function deteriorates and ESKD approaches, dialysis or transplantation will be indicated. A nephrologist will discuss further treatment options with patients and their families, depending on the medical needs of the patient as well as personal preference. Dialysis modalities include hemodialysis or peritoneal dialysis.
• If hemodialysis is preferred, patients and their families should be educated and advised to have an AV fistula created – preferably 6 to 12 months prior to the anticipated need for initiating hemodialysis.
• A CKD patient may also qualify for pre-emptive kidney transplantation. Here, the patient receives a kidney transplant form a live donor prior to the initiation of dialysis.
• Administration of Hepatitis B vaccination in the early stage of CKD reduces risk of Hepatitis B infection during dialysis or kidney transplantation. Four double doses of recombinant Hepatitis B vaccine at 0, 1, 2 & 6 months should be given, intramuscularly in the deltoid region.

A person with CKD needs early referral to a nephrologist and pre- dialysis education to decrease morbidity and mortality. Early referral reduces the rate of progression to ESKD and may delay the need to initiate kidney (renal) replacement therapy.

Whatever the underlying cause of CKD, strict control of blood pressure is the most important treatment to prevent or delay the progression of CKD. Uncontrolled blood pressure leads to rapid worsening of CKD and complications such as heart attack and stroke.

The nephrologist or physician will select appropriate agents to control

Treatment of blood pressure and anemia

Whatever the underlying cause of CKD, strict control of blood pressure is the most important treatment to prevent or delay the progression of CKD. Uncontrolled blood pressure leads to rapid worsening of CKD and complications such as heart attack and stroke.

The nephrologist or physician will select appropriate agents to control high blood pressure. The most common drugs used are angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), calcium channel blockers, beta blockers and diuretics.

ACE inhibitors and ARBs are recommended as first line therapy to reduce blood pressure and also helps by slowing the progression of kidney damage, thereby, protecting the kidneys.

It is recommended to keep blood pressure below 130/ 80 mmHg.

Periodic visits to a doctor help to know the blood pressure status. But buying a blood pressure instrument and using it regularly at home may be helpful to assess and monitor blood pressure control in CKD. Maintaining a chart of blood pressure recordings may help , the doctor adjust drug dosages and times of administration.

Doctors may prescribe diuretic which are medicines that help to increase the volume of urine and reduce swelling and breathlessness in some patients. It is important to remember that these medicines may increase the volume of urine but do not improve the function of the kidney.

When kidneys are functioning properly, they produce a hormone called

erythropoietin, which stimulates the bone marrow to produce red blood cells. In CKD with reduction of kidney function, erythropoietin production also decreases, leading to anemia.

Iron tablets, vitamins and, at times, intravenous iron injections are the first steps to treat anemia due to CKD. Severe anemia, or anemia not responding to drug therapy, needs injections of synthetic erythropoietin, which help bone marrow to produce oxygen-carrying red blood cells. Erythropoietin injections are safe, effective and the preferred method of treating anemia due to CKD. Transfusion of blood is quick and effective to correct anemia in an emergency but is not the preferred method due to the risk of infection and allergic reactions.

Red blood cells carry oxygen from lungs to all parts of the body. Anemia (low hemoglobin) in CKD leads to weakness, fatigue, poor exercise capacity, breathlessness, rapid heartbeat, loss of concentration, intolerance to cold and chest pain and therefore, this needs early and proper treatment.