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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Improving the understanding, detection, and management of kidney disease.

Slow Progression and Reduce Complications

Although CKD is generally progressive and irreversible, there are steps providers and patients can take to slow progression, enabling patients to live longer without complications or the need for renal replacement therapy. The National Institute of Diabetes and Digestive and Kidney Disease-funded Chronic Renal Insufficiency Cohort (CRIC) Study is examining risk factors for progression of CKD and the occurrence of cardiovascular disease (CVD) among patients with CKD. Insights from CRIC will inform future treatment trials and may result in revisions to treatment guidelines for risk factor reduction.

Treatment strategies to slow progression and reduce cardiovascular risk are similar. They include:

Even with these interventions, kidney disease will progress in some patients. In this case, monitoring for the associated complications and comorbidities is indicated. These may include:

Nutritional Interventions

The purpose of diet therapy in CKD is two-fold: to delay progression and to prevent and treat complications, including malnutrition. The first steps in diet therapy are to:

Choose foods that are heart healthy. As CKD progresses, the next steps may include limiting dietary phosphorus and potassium. If dietary phosphorus restriction is indicated, avoiding food with phosphorus food additives may be an appropriate first step. Adequate calories across the continuum are imperative to maintain nutritional status.

It is vital to engage a dietitian knowledgeable in CKD diet and nutrition to assess and initiate individualized medical nutrition therapy (MNT) for patients with CKD. If dietary consultation is delayed or unavailable, other providers may find NKDEP’s Eating Right for Kidney Health helpful for guiding patients on the diet. To find a dietitian near you, search the Academy of Nutrition and Dietetics directory.

*Evidence suggests that further lowering to 0.6 g protein/kg/day in patients without diabetes may be beneficial, but adherence is difficult. Some patients may be able to achieve this level with intensive counseling.

Lifestyle Interventions

Encourage health-promoting behaviors such as smoking cessation and physical activity. Cigarette smoking is associated with abnormal urine albumin and progression of CKD. Smoking also contributes to death from stroke and heart attack in people with CKD. Overall, step-down nicotine replacement therapy is generally safe, but the patient must be monitored for side effects, which may include worsening of existing hypertension and contact allergy or sensitization.

Although people with CKD tend to be less active, the goals for physical activity are the same as in the general population, at least 20 to 30 minutes every day. To improve or prevent deconditioning, both aerobic and strength training should be encouraged. Physical activity may help prevent cardiovascular disease, improve glucose control in those with diabetes, and maintain muscle mass.

Evidence suggests that providing self-management education to patients with chronic disease results in reduced health service utilization and improved health behaviors and health status beyond that achieved by usual care.

Medical Management

Key interventions include blood pressure control, blockade of the renin-angiotensin aldosterone system (RAAS) with ACE inhibitors or ARBs, and blood glucose control in those with diabetes. The use of ACE inhibitors and ARBs has been found to slow progression of CKD and is considered first-line treatment in patients with albuminuria.

Strategies for slowing progression:

Blood Pressure Control

High blood pressure is both a cause and complication of CKD. Uncontrolled high blood pressure can accelerate the loss of GFR. Blood pressure control usually requires a combination of antihypertensive medications and lifestyle modifications.

The panel members appointed to the eighth Joint National Committee (JNC 8) recently completed an extensive review of evidence around management of hypertensive adults. Due to insufficient evidence for blood pressure goals in the CKD population, the Panel recommended treating to a blood pressure goal of less than 140/90 mm Hg for people with CKD based on expert opinion. Additionally, the panel recommended initial treatment with ACE inhibitors or ARBs for hypertensive patients with CKD. However, the Panel emphasized that the recommendations should not override clinical judgment and decisions about care should consider individual patient circumstances.

The SPRINT trial, currently underway, will examine a range of blood pressure goals in patients with CKD.

Monitor Blood Pressure

Routine monitoring of blood pressure is recommended for all patients with CKD. The following techniques are recommended:

Treat High Blood Pressure

Antihypertensive medications and lifestyle modifications are the cornerstones for treating high blood pressure.

ACE inhibitors and ARBs have been shown to slow the progression of CKD, particularly in patients with albuminuria. These medications lower glomerular capillary blood pressure as well as systemic blood pressure. These classes of drugs may also be considered in glomerular (albuminuric) kidney disease when hypertension is not present. Monitor for hyperkalemia when prescribing these medications.

If the patient is not meeting the blood pressure goal, review

Reduce Albuminuria

Elevated urine albumin is associated with increased risk of renal events and lowering urine albumin may decrease the risk of progression.. ACE inhibitors and ARBs have been shown to slow the progression of CKD, which may be reflected in decreased albuminuria. These medications lower glomerular capillary blood pressure as well as systemic blood pressure. They may also be considered in glomerular (albuminuric) kidney disease when hypertension is not present. Sodium restriction may enhance the effectiveness of these medications.

Weight loss, lowering dietary sodium and restriction of excessive dietary protein intake may reduce albuminuria. Refer to a registered dietitian knowledgeable in the CKD diet, as needed.

Blood Glucose Control

Achieving and maintaining optimal glucose control may reduce the risk of developing albuminuria. Intensive glycemic control lessens progression of albuminuria in type 1 diabetes; benefits in type 2 are less clear. Current guidelines for diabetes recommend achieving a goal of the A1C of less than 7 percent. However, recent evidence emphasizes the importance of individualizing therapeutic goals.

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References »

James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J, Lackland DT, LeFevre ML, MacKenzie TD, Ogedegbe O, Smith SC Jr, Svetkey LP, Taler SJ, Townsend RR, Wright JT Jr, Narva AS, Ortiz E. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014; 311(5):507-20.

Pickering TG, Hall JE. Appel LA, et al. Recommendations for blood pressure measurement in humans and experimental animals: Part 1: Blood pressure measurement in humans: A statement for professionals from the subcommittee of professional and public education of the American Heart Association council on high blood pressure research. Circulation. 2005;111(5):697-716.

Upadhyay A, Earley A, Haynes SM, Uhlig K. Systematic review: blood pressure target in chronic kidney disease and proteinuria as an effect modifier. Annals of Internal Medicine. 2011; 154(8):541-548.

Weir MR, Rolfe M. Potassium homeostasis and renin-angiotensin-aldosterone system inhibitors. Clinical Journal of the American Society of Nephrology. 2010;5(3): 531-548.

Page last updated: September 17, 2014