Reducing Kidney Function Decline in Patients With CKD: Core Curriculum 2021

Abstract

An estimated 8% to 16% of the world's population has chronic kidney disease, defined by low glomerular filtration rate or albuminuria. Progression of chronic kidney disease is associated with adverse outcomes, including incident kidney failure with replacement therapy, accelerated cardiovascular disease, disability, and mortality. Therefore, slowing kidney function decline is paramount in the management of a patient with chronic kidney disease. Ascertaining the cause of kidney disease is an important first step and may compel specific therapies. Effective approaches that apply to the vast majority of patients with chronic kidney disease include the optimization of blood pressure and blockade of the renin-angiotensin-aldosterone system, particularly if albuminuria is present. Recent studies suggest that sodium/glucose cotransporter 2 inhibitors are highly effective treatments in patients with diabetes and/or albuminuria. For patients with type 2 diabetes, glycemic control is important in preventing the development of microvascular complications, and glucagon-like peptide 1 receptor agonists may help reduce albuminuria levels. Other strategies include correcting metabolic acidosis, maintaining ideal body weight, following diets that are low in sodium and animal protein, and avoiding potential nephrotoxins such as nonsteroidal anti-inflammatories, proton-pump inhibitors, and iodinated contrast.

Keywords: Albuminuria; CKD progression; blood pressure (BP); chronic kidney disease (CKD); diabetes; estimated glomerular filtration rate (eGFR); glucagon-like peptide 1 receptor agonist (GLP1-RA); glycemic control; hypertension management; lifestyle modification; proteinuria; renal function; review; sodium/glucose cotransporter 2 inhibitor (SGLT2i); uric acid.

Figure 1:

Kaplan-Meier curves for renal events by tertiles of 24-hour urinary sodium-creatinine ratio (<121 mmol/g; 121 to <153 mmol/g; ≥153 mmol/g) among RENAAL and IDNT trial participants on non-RAASi-based therapy and ARB therapy. Renal event defined as a doubling of serum creatinine from baseline or KFRT (RENAAL and IDNT) or serum creatinine ≥6.0 mg/dL (IDNT only). Adapted from Heerspink et al 2012 (Kidney Int. https://doi.org/10.1038/ki.2012.74) with permission of the copyright holder. Original graphic © 2012 International Society of Nephrology. Abbreviations: Non-RAASi=non-renin-angiotensin-aldosterone system inhibitor; ARB=angiotensin receptor blocker.

Figure 2:

Proposed algorithm for SGLT2 inhibitor and GLP-1 receptor agonist use in chronic kidney disease. Metabolic risks factors include uncontrolled diabetes or obesity/weight gain. Based on information in Li et al 2020 (Clin J Am Soc Nephrol. https://doi.org/10.2215/CJN.02690320). Abbreviations: SGLT2=sodium/glucose cotransporter 2; GLP-1=glucagon-like peptide 1; eGFR=estimated glomerular filtration rate; UACR=urinary albumin-creatinine ratio; ASCVD=atherosclerotic cardiovascular disease; HF=heart failure.

Figure 3:

Mean (± standard errors) estimated glomerular filtration rates among patients with CKD G3 randomized to usual care, sodium bicarbonate supplementation, base-producing fruits and vegetables. Reproduced from Goraya et al 2014 (Kidney Int. https://doi.org/10.1038/ki.2014.83) with permission of the copyright holder. Original graphic © 2014 International Society of Nephrology. Abbreviations: crGFR=plasma creatinine-based glomerular filtration rate; cysGFR=plasma cystatin C-based glomerular filtration rate; HCO₃=sodium bicarbonate supplementation; F+V=fruits and vegetables.