Management of chronic kidney disease

Management of chronic kidney disease (CKD) requires a systematic approach that includes all components of the chronic disease model. NICE guidance now combines eGFR and albumin:creatinine ratio in CKD staging to improve prediction of the risk of adverse outcomes and to recommend frequency of monitoring. Some causes of CKD require specific management directed at the underlying cause. For many patients, control of cardiovascular risk factors is the most important intervention, as these risk factors also promote progressive loss of kidney function. More intensive reduction of blood pressure and the use of inhibitors of the renin–angiotensin axis are recommended for patients with diabetes and/or significant proteinuria, but excessive blood pressure reduction can be harmful. Reducing the level of proteinuria is a further therapeutic goal. Dietary salt restriction is an important adjunct to drug therapy. Smoking cessation, obesity correction, lipid-lowering treatment and (among patients with diabetes mellitus) glycaemic control are also important. The dosage of drugs that are cleared by the kidney should be adjusted; care must be taken to avoid nephrotoxic drugs. Hypovolaemia and hypotension can further damage kidney function and should be avoided, or treated promptly. Symptoms are common only in advanced CKD. Patients likely to progress to established renal failure should be referred early enough to allow adequate preparation for renal replacement therapy.