Medical Care: Progression from CKD to ESRD can be slowed by a variety of measures, including aggressive control of diabetes, hypertension, and proteinuria. Dietary protein restriction, phosphate restriction, and hyperlipidemia control may have significant impact on retarding disease progression. Specific therapies for some glomerular diseases (eg, lupus) should be implemented in appropriate settings. Aggressively manage anemia and hypocalcemia before renal replacement therapy. Also, aggressively manage comorbid conditions such as heart disease and diabetes.
" The target blood pressure for patients with proteinuria greater than 1 g/d is less than 125/75 mm Hg; for patients with proteinuria less than 1 g/d, the target blood pressure is less than 130/80 mm Hg.
o Angiotensin-converting enzyme inhibitors (ACEIs) are commonly used and are usually the first drug of choice for treatment of hypertension in patients with CRF. ACEIs are renoprotective agents that have additional benefits beyond lowering blood pressure. ACEIs effectively reduce proteinuria, in part by reducing the efferent arteriolar vascular tone, thereby decreasing intraglomerular hypertension. Particularly, ACEIs have been shown to be superior to conventional therapy in slowing the decline of the GFR in patients with diabetic and nondiabetic proteinuric nephropathies. Therefore, consider ACEIs for treatment of even normotensive patients with significant proteinuria.
o The role of angiotensin II receptor blockers in renal protection is increasingly being established, and these medications have been found to retard the progression of CKD in patients with diabetic or nondiabetic nephropathy in a manner similar to that of ACEIs.
o Diuretics are often required because of decreased free-water clearance, and high doses may be required to control edema and hypertension when the GFR falls to less than 25 mL/min.
o Beta-blockers, calcium channel blockers, central alpha-2 agonists (eg, clonidine), alpha-1 antagonists, and direct vasodilators (eg, minoxidil, nitrates) may be used to achieve the target blood pressure.
" Renal osteodystrophy can be managed early by replacing vitamin D and administering phosphate binders. Seek and treat nonuremic causes of anemia, such as iron deficiency, before instituting therapy with erythropoietin.
" Discuss options for renal replacement therapy, eg, hemodialysis, peritoneal dialysis, or transplantation. Arrange permanent vascular access when the GFR decreases to less than 20-25 mL/min or if the rate of rise in the serum creatinine level indicates the need for dialysis within 2-6 months. Arteriovenous fistulas are preferred to arteriovenous grafts because of their long-term high-patency rates and should be placed whenever possible. Place peritoneal dialysis catheters 2-3 weeks prior to anticipated dialysis therapy.
" Treat hyperlipidemia (if present) to reduce overall cardiovascular comorbidity, even though evidence for renal protection is lacking.
" Expose patients to educational programs for early rehabilitation from dialysis or transplantation.
Surgical Care: Create access for dialysis when the GFR decreases to less than 25 mL/min.
Diet:
" Protein-restricted diets (0.4-0.6 g/kg/d) are controversial but may be beneficial in slowing the decline in the GFR and in reducing hyperphosphatemia (serum phosphate level >5.5 mg/dL) in patients with serum creatinine levels of greater than 4 mg/dL. Monitor these patients for signs of malnutrition.
" Educate patients about how diets rich in potassium help control hyperkalemia.
" Many dietary restrictions are no longer necessary with the initiation of renal replacement therapy.
Activity:
" Encourage patients to increase their activity level as tolerated. Increased activity may aid in blood pressure control.