Most patients with stable CKD can be fully managed in primary care, particularly patients with stable stage 3 CKD or
those patients aged over 75 years with early and stable stage 4 CKD.2 The most important aspects of CKD management
are:
- Controlling blood pressure; and if the patient has diabetes
- Controlling blood glucose
Patients with stable CKD (stage 3 – 4) have a five-year cardiovascular risk > 15%, if they do not have diabetes, which
increases to > 20% if diabetes is also present. These patients need appropriate cardiovascular disease management and
it is important that additional medicines, e.g. statins and aspirin, are initiated according to cardiovascular guidelines
to reduce cardiovascular risk.
Complementary community-based care strategies involving nurse-led teams have been shown to improve outcomes in patients
with moderate CKD who are at high-risk of progressing to kidney failure (see:” Delaying nephropathy in Māori and Pacific
patients”).
Software-based decision support, audit and patient recall systems are an important part of best practice in the management
of CKD.
Lifestyle management of chronic kidney disease
Patients with CKD are able to reduce their rate of renal function decline through lifestyle modifications. Reductions
in systolic blood pressure are often used to quantify the benefits of lifestyle modification in patients with CKD because
this is known to have a renal-protective effect. Examples of lifestyle modifications and their approximate effect on systolic
blood pressure include:2
- Reducing BMI to at least ≤ 30 kg/m2 with an ideal target of ≤ 25 kg/m2. Alternatively a
waist circumference for males < 102 cm and a circumference < 88 cm for females. A 10 kg reduction in weight results
in a reduction in systolic blood pressure of 5 – 20 mmHg.
- Moderate intensity physical activity ≥ 30 minutes/day results in a 4 – 9 mmHg reduction in systolic blood pressure
- Reducing dietary salt intake to ≤ 6 g/day results in a reduction in systolic blood pressure of 2 – 8 mmHg. This can be achieved
by choosing to consume fresh vegetables and fruit, fish, milk, unprocessed meats, and using less salt in cooking and at
the dinner table.
- All patients with CKD can be advised to observe at least two alcohol-free days per week. Upper limits for alcohol consumption
for females are no more than two standard drinks per day, and no more than ten standard drinks a week. Males should be
encouraged to drink no more than three standard drinks per day, and no more than 15 standard drinks per week. Reducing
alcohol consumption to moderate levels can result in a 2 – 4 mmHg reduction in systolic blood pressure.
Smoking is an important modifiable risk factor for CKD progression.9 The few studies that have been conducted
on the effects of smoking cessation in patients with CKD have found that albuminuria is significantly decreased and progression
of diabetic nephropathy slowed.9 Encouraging smoking cessation in any patients with CKD is a priority of care.
Patients with CKD can be advised to maintain a normal daily intake of protein, i.e. 0.75 – 1 g/kg/day.2 This
equates to 60 – 80 g of protein a day for an 80 kg person, e.g. approximately 250 g of lean beef or chicken breast or 300
g of canned tuna.10 High-protein diets, i.e. > 1.3 g/kg/day, are not recommended in patients with CKD at
risk of progression due to the risk of further kidney damage.5 Low-protein diets are also not recommended as
insufficient dietary protein can lead to malnutrition, particularly in older patients.5
For further information see:
www.nutritionfoundation.org.nz/nutrition-facts/Nutrients/protein
Pharmacological treatment of chronic kidney disease
Managing blood pressure is a cornerstone of CKD management both to slow the rate of CKD progression and to reduce the
patient’s cardiovascular risk.
The target blood pressure for patients with CKD is:2
- ≤ 130/80 mmHg for patients with diabetes or proteinuria with an ACR > 30 mg/mmol
- ≤ 140/90 mmHg for most other patients
However, blood pressure targets may need to be flexible and in older patients, e.g. aged over 70 years, a blood pressure
target of < 150/90 mmHg may be reasonable.1 When prescribing antihypertensive medicines to older patients
doses should be gradually increased and the patient monitored for adverse effects such as dizziness, orthostatic hypotension,
electrolyte imbalances and acute kidney injury (AKI).5 Blood pressure control should also aim to reduce the
levels of proteinuria by more than 50%.2
Angiotensin converting enzyme (ACE) inhibitors are the first-line treatment for controlling blood pressure in patients
with CKD.2 Angiotensin II receptor blockers (ARBs) are an alternative if ACE inhibitors are not tolerated.2 The
combination of ACE inhibitors and ARBs should be avoided when treating patients with CKD in primary care.2 Follow-up
in the early stages of treatment, i.e. two to four weeks, is useful to ensure the patient is responding adequately to antihypertensive
treatment.1
Many patients will require multiple medicines to achieve blood pressure targets and this need increases as a patient’s
eGFR declines.2 It is recommended that a calcium channel blocker be added to an ACE inhibitor or ARB as the
second stage in managing hypertension in patients with CKD.11
For further information see: “Hypertension
in Adults: The silent killer.” BPJ 54 (Aug, 2013).
Glycaemic control
In patients with CKD and diabetes, glycaemic control is essential to prevent or delay the progression of the microvascular
complications of diabetes, including diabetic nephropathy, and to reduce cardiovascular risk.5 A HbA1c target < 53
mmol/mol is generally appropriate for patients with CKD and diabetes, although in patients at risk of hypoglycaemia, e.g.
older patients living alone, or in patients with co-morbidities or limited life expectancy, a target HbA1c ≥ 53
mmol/mol may be more appropriate; this should be discussed with patients using a shared-decision making approach.5
In patients with advanced stage 4 and stage 5 CKD the risk of hypoglycaemia is also clinically relevant, and less intensive
glycaemic control but with close monitoring is often required.1
The maximum dose of metformin in patients with an eGFR < 60 mL/min/1.73m2 is metformin
1 g, daily.12 Metformin should be avoided altogether in patients with an eGFR < 30 mL/min/1.73m2 except
under the close supervision of a nephrologist.12
For further information see: “Getting
to know patients with type 2 diabetes and poor glycaemic control: One size does not fit all” BPJ 58 (Feb, 2014).
Treat hyperlipidaemia according to cardiovascular risk
Statin treatment for hyperlipidaemia should be discussed, where appropriate, with patients with CKD. The benefits of
statin treatment in patients with CKD is relatively consistent in patients with a broad range of LDL cholesterol levels.5 However,
statins are less effective in patients with advanced CKD.2 Fibrates should be avoided in patients with reduced
renal function due to the increased risk of a myositis-like syndrome occurring.12 The optimal lipid levels for
patients with CKD are:2
- Total cholesterol < 4.0 mmol/L
- LDL cholesterol < 2.0 mmol/L
- HDL cholesterol ≥ 1.0 mmol/L
- Triglycerides < 1.7 mmol/L
Gout is common in people with chronic kidney disease
Chronic kidney disease is reported to be the third most prevalent risk factor for gout, following obesity and hypertension.13 This
is because reduced renal function in patients with CKD can result in uric acid levels being raised, causing gout symptoms
in some patients.14 According to international estimates 40 – 50% of patients with gout also have CKD.15 Gout
is associated with increased cardiovascular risk in patients with CKD. Gout is present in 11.7% and 13.5% of Māori and
Pacific males, compared to 3.7% of European males, and 4% of Māori and Pacific females, compared to less than 1% of European
females.16
Monitoring of renal function in patients with CKD and gout is particularly important as many of the medicines used to
treat patients with gout are potentially nephrotoxic. Allopurinol is the first-line medicine used to reduce uric acid levels.
Initial doses of allopurinol should be low and determined by eGFR in patients with CKD, and then slowly titrated to achieve
a serum uric acid level of < 0.36 mmol/L.17 This slow titration of allopurinol reduces the risk of patients
experiencing the relatively rare allopurinol hypersensitivity syndrome. All non-steroidal anti-inflammatory drugs (NSAIDs)
are associated with potentially nephrotoxic effects and should be used with caution to treat attacks of acute gout in patients
with CKD. Oral prednisone is a treatment option for the management of acute gout attacks in patients with CKD.12 Colchicine
remains a useful treatment option in patients with stage 1 or 2 CKD, but should be avoided in patients with an eGFR < 60
mL/min/1.73m2.12
For further information see: “Allopurinol
dosing in renal impairment” BPJ 61 (Jun, 2014).