The Early Diagnosis and Treatment of Chronic Renal Insufficiency

Abstract

Background: Chronic renal insufficiency (CRI) is becoming more common and has an increasing impact on public health. In Germany, approximately one in ten adults has CRI. Its most serious consequence is generally not the development of end-stage renal failure, but rather the markedly increased cardiovascular risk as kidney function declines.

Methods: This review is based on the findings of a selective search in PubMed for literature about the treatment options for CRI, and on our overview of the existing guideline recommendations on diagnostic testing. .

Results: Patients with diabetes mellitus and arterial hypertension are at especially high risk of developing CRI. For these patients, some of the guidelines recommend regular testing for albuminuria and measurement of the glomerular filtration rate (GFR), though sometimes only when specific risk constellations are present. The treatment of CRI has evolved in recent years. At first, aside from general measures, only RAS inhibitors were available as a specific therapy for CRI. With the extension of the approval of SGLT-2 inhibitors to non-diabetic CRI patients, the options for treatment have become wider. Two randomized controlled trials have revealed the benefit of SGLT-2 inhibitors with respect to their primary combined endpoints: time to a specified eGFR reduction and renal/cardiovascular death (HR 0.61 [0.51; 0.72] and 0.72 [0.64; 0.82]). The potential side effects and contraindications of SGLT-2 inhibitors must be taken into account. A further treatment option for diabetics with CRI has become available with the approval of the non-steroidal mineralocorticoid receptor antagonist finerenone.

Conclusion: In patients with risk factors, renal function should be regularly tested.

Figure 1

Stages of chronic kidney disease according to KDIGO* *Nephrological Heat Map (from the consensus report of ADA and KDIGO on diabetes management in CKD patients with diabetes; for German translation adapted from [21]). The combination of eGFR and albuminuria reflects the individual risk of patients with regard to cardiovascular events, acute kidney failure, progression of chronic kidney disease, and end-stage kidney disease. In addition, recommendations are made on when to start treatment or refer the patient to a nephrologist. The German Society of Nephrology (DGfN) recommends to involve a nephrologist in the care of patients with macroalbuminuria and/or an eGFR of less than 45 mL/min. The heat map also provides information on the recommended frequency of nephrological monitoring (1–4+ times per year). Even simpler it is in clinical practice to use the so-called rule of 10, in which the eGFR divided by ten indicates the number of months between nephrological follow-up examinations.. ADA, American Diabetes Association; CKD, Chronic kidney disease; eGFR, estimated glomerular filtration rate; KDIGO, Kidney Disease: Improving Global Outcomes.

Figure 2

Possible explanatory mechanism for the nephroprotective effect of SGLT-2 inhibitors. Overall, a number of different effects are contributing to the reduction in albuminuria. GBM, glomerular basement membrane adapted from (e9)

Figure 3

Summary of the current KDIGO guidelines on the general treatment recommendation for patients with type 2 diabetes and CKD. It is important to note that metformin and SGLT-2 inhibitors are treated as being of equal status. Adapted from (32). ASCVD, atherosclerotic cardiovascular disease; BP, blood pressure; CCB, calcium channel blocker; eGFR, estimated glomerular filtration rate; MRA, mineralocorticoid receptor antagonist; ns-MRA, non-steroidal mineralocorticoid receptor antagonist; pts, patients; RA, receptor agonist; T1DM, type 1 diabetes mellitus; T2DM; type 2 diabetes mellitus