MANAGEMENT OF CKD
Vassalotti JA, Centor R, Turner BJ, et al; US Kidney Disease Outcomes Quality Initiative. A practical approach to detection and management of chronic kidney disease for the primary care clinician. Am J Med. [Epub ahead of print September 25, 2015]. doi: 10.1016/j.amjmed.2015.08.025.
This guideline was developed for the primary care provider to guide assessment and care of chronic kidney disease (CKD). Recommendations include
• Assessment of estimated glomerular filtration rate (GFR) and albuminuria should be performed for persons with diabetes and/or hypertension but is not recommended for the general population.
• Prevention of CKD progression requires blood pressure < 140/90 mm Hg, use of ACE inhibitors or angiotensin receptor blockers (ARB) for patients with albuminuria and hypertension, A1C < 7% for patients with diabetes, and correction of CKD-associated metabolic acidosis.
• Nephrotoxic drugs (eg, NSAIDs) should be avoided, and providers should be aware to use reduced doses of medications that are renally excreted, such as insulin, many antibiotics, and some statins.
The ultimate goal of CKD management is to prevent disease progression, minimize complications, and promote quality of life.
COMMENTARY
More than 10% of the US population has CKD, defined as a GFR < 60 mL/min/1.73 m2 and/or albumin-creatinine ratio > 30 mg/g. Both GFR and albuminuria independently predict progression of CKD. Control of blood pressure and A1C and use of an ACE inhibitor or an ARB are well-appreciated methods of slowing CKD progression. What is not as well appreciated is that treatment with ACE inhibitors or ARBs remains renal protective even with GFR < 30. Also important is the use of oral alkali therapy to maintain normal serum bicarbonate levels, which may slow CKD progression. When bicarbonate levels decrease to < 22 mmol/L, sodium bicarbonate (650 mg tid) should be added to raise the bicarbonate level above 22 mmol/L. For patients with severe CKD, referral to a nephrologist is appropriate.