|Through an Expert's Eyes|
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Pre-ESRD Prevention Programs: Slowing the Plight of CKD
An estimated 26 million people in the United States have chronic kidney disease (CKD), many of which are unaware of their condition. Nearly 50 percent of elderly over 70 will develop CKD during their lifetime. Fortunately, only a small percentage of these patients will progress to end-stage renal disease (ESRD). In the last two decades, pre-ESRD programs for those in the early stages of CKD, have demonstrated effective strategies for delaying or preventing the need for renal replacement therapy.
Hypertension and diabetes cause the greatest disease burden resulting in renal failure. Sadly, a large portion of patients on dialysis today could have avoided the devastating consequences of renal failure by an early focus on proven prevention strategies including exercise, weight loss and pharmacologic interventions. For those patients already in end-stage renal failure at the time of diagnosing their kidney disease, emergency dialysis places them at the highest risk of death and complications as compared to CKD patients with a timely referral to nephrologists for pre-ESRD care.
Non-pharmacologic interventions that apply to the general population including smoke cessation, reduced alcohol intake, regular aerobic exercise, reduced sodium intake, control of cholesterol and diabetes are favored by a consensus of expert opinion. There are very few randomized and controlled trials of non-pharmacologic interventions available to guide in the development of a pre-ESRD program. For those patients with excessive protein in the urine, low protein diets are the current standard of care for slowing the progression of the underlying renal disease despite convincing evidence to date from randomized and controlled trials.
The 1994 Modification of Diet in Renal Disease (MDRD) study found a trending decline in renal disease progression with lower levels of proteinuria from dietary restriction of protein. When combined with blood pressure control of 130/80 mm Hg in diabetic patients and 125/75 in patients with proteinuria greater than 1 gram a day, dietary protein restriction may be beneficial. However, close monitoring of albumin and protein levels to prevent the malnutrition-inflammation complex syndrome, which is associated with increased mortality in patients with CKD, limits the application dietary protein restriction. Paradoxically, CKD patients with obesity, higher cholesterol and more muscle mass have a greater survival advantage.
Angiotensin-converting enzyme inhibitors (ACEIs) are beneficial, especially for patients with CKD caused by diabetes as well as other diseases. These agents reduce proteinuria independent of their blood pressure lowering effects and are more effective than other antihypertensive agents. For those with intolerance for ACEIs, angiotensin II receptor blockers (ARBs) are an effective alternative in many patients. Studies show that effective blood pressure control requires two to three blood pressure medications in most cases. Recent studies reveal worsening decline of renal function when ACEIs are combined with ARBs in most patients, and this combination is now avoided.
Many commonly used medications may worsen renal function, and avoiding these nephrotoxic agents prevents further decline. Over the counter pain medications called non-steroidal anti-inflammatory drugs (NSAIDS) such as Motrin, Advil and Alive can cause acute renal failure in patients with underlying renal compromise. In addition, contrast agents for imaging studies and certain types of antibiotics must be used with great diligence or seek alternative diagnostic and treatment options. One area overlooked are herbal remedies, which many nephrologists may not know the patient is taking. Physicians must take careful medication histories including herbal remedies and develop patient education on their adverse effects to reduce this risk.
Most large integrated health care organizations now incorporate algorhythms for early referral to nephrologists for patients with a GFR between 30-45 ml/min/1.73m. Treatment of common CKD co-morbid conditions and cardiovascular disease complete the basic prevention strategies. Fortunately, this benefits both the patient and the health care providers by reducing the number patients progressing to ESRD and dialysis.
Understanding the profound impact of ESRD on patients lives; the current standard of care is an effective pre-ESRD program. In many ways, these programs demonstrate the best of integrated medicine systems in reducing the personal impact of this all too prevalent disease and at the same time reducing hospital and outside medical costs. With the threat of the obesity epidemic and the long-term health consequences, pre-ESRD programs cast light on one effective health care strategy that could be utilized as a model for other chronic health diseases as well.
Dr. Laird is an internal medicine specialist with nearly 20 years of clinical practice in hospital medicine, office practice and acute care medicine. Since 2007, Dr. Laird has required renal replacement therapy with hemodialysis due to underlying IgA nephropathy, a progressive renal disease. Dr. Laird now dialyzes at home with the assistance of his wife Marilou and is an outspoken advocate for wider access to optimal dialysis strategies. He has a personal blog where he shares his views on all renal issues.