Recent important strategies in the management of chronic kidney disease

Abstract

The burden of chronic kidney disease (CKD) is considerably higher in low-and middle-income countries, which are less able than the developed world to cope with treating advanced renal failure owing to financial constraints. Prevention, early diagnosis and implementation of existing knowledge can improve outcomes. This review presents several recent advances to assist with avoiding and slowing down CKD progression and reducing common comorbid complications. The following are discussed: the possible use of metformin in patients with type 2 diabetes-related CKD; recent inexpensive important developments in the treatment of autosomal-dominant polycystic kidney disease; prevention of acidosis and the early dietary reduction of red meat consumption; and the therapeutic lowering of uric acid in persistent hyperuricaemia. Finally, an active and monitored exercise programme should be undertaken whenever possible. All of these recommendations have been shown to significantly slow the progression of CKD and increase cardiovascular protection. CME 731September 2017, Vol. 107, No. 9 CME addition to the multiple cardiovascular and renal complications of DM, renal dysfunction in the elderly is further compounded by the slow but progressive fall in glomerular filtration rate (GFR) in persons >45 years of age (i.e. ±1 mL/min/year) and also because people live longer. For many years the US Food and Drug Administration (FDA), the Regulatory Cooperation Council (RCC) in Canada and other regulatory bodies have indicated that the use of MF is contraindicated in patients with mild and moderate CKD (stages 3a and 3b) owing to the rarely reported but life-threatening complication of lactic acidosis (LA) (serum lactate levels ≥15 mmol/L).That LA does not occur in patients who receive MF, with an estimated GFR (eGFR) of 50 -30 mL/min., has been indicated in studies conducted by Inzucchi et al. [13] They showed that MF can be safely used in these patients, provided that certain guidelines are always followed. A Coch rane meta-analysis conducted on 47 096 patients with a follow-up of 86 067 patient-years compared the incidence of LA in patients who received MF with those who did not, irrespective of the eGFR.[14] They found that for the upper limit of 95% confidence the true incidence of LA was 6.3/100 000 patient-years for the MF group and 7.8/100 000 patient-years for the non-MF group.It is important to remember that before prescribing MF for any degree of renal function, certain rules are essential and must be fully adhered to. As many practitioners are either unaware or uncertain of the predisposing conditions, these are set out in Table 4.Mechanisms of MF-associated LA are not well elucidated, but include conversion of glucose to lactate in the splanchnic bed and inhibition of hepatic gluconeogenesis (i.e. from lactate, pyruvate and adenine). [15,16] It is essential that any patient with the abovementioned precipi ta ting disorders is instructed to immediately but temporarily withdraw the use of MF and present to a doctor. Patients h...

Chronic kidney disease

“…In SA, however, the huge costs of dialysis and transplantation dictate that our CKD management should first and foremost be aimed at prevention and, secondly, at renoprotection. The review presented in the CME section of SAMJ [2] highlights recent information relating to the use of metformin in the management of diabetes in patients with CKD, the essential and early treatment of CKD acidosis (i.e. estimated glomerular filtration rate (eGFR) ≤59 mL/min), early dietary therapy, early lowering of serum uric acid and the introduction of adequate and ongoing exercise -all aimed at slowing the progression of CKD.…”