Management of chronic kidney disease

Management of chronic kidney disease (CKD) requires a systematic approach that includes all components of the chronic disease model. National guidelines are now available for the identification, management and referral of CKD. Some causes of CKD require specific additional 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/or the use of inhibitors of the renin/angiotensin axis are recommended in the treatment of proteinuric kidney disease, including diabetic nephropathy. In these patients, treatment should be adjusted to achieve maximum reduction of urine protein excretion; dietary salt restriction is an important adjunct to drug therapy. Smoking cessation, correction of obesity, and (amongst patients with diabetes mellitus) glycaemic control are also important. The role of lipid-lowering therapy in reducing the risk of progressive CKD remains to be fully defined. Drug dose adjustment is required for those drugs that are cleared by the kidney, and care must be taken to avoid nephrotoxic drugs. Acute hypovolaemia and hypotension can further damage kidney function and should be avoided, or treated promptly. Patients with CKD require life-long follow-up; this can commonly be achieved most efficiently in the primary care setting. 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.