Management of chronic failure is divided into two protocols, depending on remaining kidney functions.
Pre dialysis protocol and dialysis protocol
Why to separate into two protocols, it is due to the objectives of management
| Pre dialysis objectives | Dialysis objectives |
| Slow down the disease progression | Keep the patient healthy |
| Manage the sign and symptoms | Minimize mortality and morbidity |
Slow down the disease progression
The progression of CKD, regardless of its underlying cause, is associated with poorly controlled hypertension. Consequently, the control of hypertension is considered the single most important intervention to slow the progression of CKD. Target levels of BP have been set by different organizations and societies at <130/80mmHg; lower targets have been advocated in those with moderate to heavy proteinuria (>1 g/24 h) and in those with diabetic nephropathy. In these diabetic and proteinuric patients, with a faster rate of decline in GFR, the use of inhibitors of the angiotensin system such as ACEIs and ARBs has been recommended. In nondiabetic and nonproteinuric nephropathies, there is little evidence that these agents have a therapeutic advantage and national BP control recommendations should be followed. The initial combination of a diuretic and calcium antagonist is thought to have the best risk benefit profile and be the most cost-effective for nondiabetic and nonproteinuric nephropathies
Reduce proteinuria hence, the use of ACEIs and ARBs alone or in combination in proteinuric CKD patients with or without diabetic nephropathy. The addition of a diuretic or dietary salt restriction (<60 mmol/day) enhances the antiproteinuric effect of angiotensin inhibition. CKD patients should be advised to reduce their dietary salt intake. It is also important to closely monitor CKD patients started on ACEIs or ARBs, as these agents can seriously compromise kidney function in susceptible individuals (those with renal artery stenosis) as well as induce hyperkalemia. It is therefore advised that renal function test should be repeated within 1 week of treatment initiation and again at 4 weeks. An increase in serum creatinine value exceeding 25% of the baseline value should lead to immediate discontinuation of the treatment
- Treat any reversible causes such as obstruction with early ultrasound imaging, particularly in the elderly.
• Establish the rate of progression by calculating the rate of fall of eGFR (mL/min/1.73 m2/year).
• Optimize BP control :< 130/80 mmHg and possibly lower in diabetic nephropathy and proteinuric nephropathies (>1 g/24 h).
• Start with ACEIs or ARBs in proteinuric and diabetic nephropathies (with proteinuria).
• If BP is uncontrolled and/or if proteinuria > 1 g/24 h, increase the dose of ACEI or ARB and add diuretic (loop diuretic if GFR < 30 mL/min) and dietary salt restriction (<60 mmol/day).ACEIs and ARBs can be administered in combination
- Closely monitor changes in serum creatinine/GFR. Stop ACEI or ARB if the GFR falls by more than 25% at 1–4 weeks after initiation or change of regimen.
• In nonproteinuric, nondiabetic CKD, calcium antagonist and diuretic are an alternative antihypertensive treatment.
• Third-line therapy could consist of alpha or beta-blockade, depending on associated comorbidities; a cardio selective beta blocker would be preferred in patients with a history of CVD.
• If BP remains uncontrolled, consider the underlying diagnosis of renovascular hypertension and atherosclerotic renal artery stenosis/ischemic nephropathy.
• Avoid acute decline of GFR precipitated by intercurrent illnesses such as volume depletion in diarrheal states or vomiting as well as by the use of NSAIDs, aminoglycosides, and contrast agents in diagnostic imaging. The latter should be avoided if there is any alternative approach for diagnosis; otherwise, use precautions judiciously in these circumstances
Management guidelines for reducing CKD complications.
- CVD control Hypertension, dyslipidemia, smoking, anemia, renalosteodystrophy
- Hypertension control blood pressure less than 130/80 mmHg
- Hypercholesterolemia: usage of Statins, target total cholesterol < 5 mmol/L and LDL cholesterol < 2.1 mmol/L
- Anemia: Correct deficiencies, Hemoglobin: 11–12 g/dL, Serum ferritin: 500–800 µmol/L and serum folic acid 2–5 mg/mL, erythropoietin 4000–10,000/units/week according to hemoglobin level
- Calcium (Ca): 2.1–2.3 mmol/L, treat, hypocalcemia, administer Vitamin D
- Phosphorus: 1.2–1.7 mmol/L, Correct hyperphosphatemia, use phosphate binders
- Parathyroid hormone2–3 times upper limit (PTH) of normal (150–300 pg/mL)
- Nutrition: Avoid malnutrition, Serum albumin >40 g/L Protein intake 0.8 g/kg/day (CKD stages 3–5) Calories: 35 kcal/kg/day
- Infections: give Immunization against, Chest infections: influenza and pneumococcus, Hepatitis B Vaccination CKD