Reducing Kidney Function Decline in Patients With CKD: Core Curriculum 2021

Abstract

An estimated 8% to 16% of the world's population has chronic kidney disease, defined by low glomerular filtration rate or albuminuria. Progression of chronic kidney disease is associated with adverse outcomes, including incident kidney failure with replacement therapy, accelerated cardiovascular disease, disability, and mortality. Therefore, slowing kidney function decline is paramount in the management of a patient with chronic kidney disease. Ascertaining the cause of kidney disease is an important first step and may compel specific therapies. Effective approaches that apply to the vast majority of patients with chronic kidney disease include the optimization of blood pressure and blockade of the renin-angiotensin-aldosterone system, particularly if albuminuria is present. Recent studies suggest that sodium/glucose cotransporter 2 inhibitors are highly effective treatments in patients with diabetes and/or albuminuria. For patients with type 2 diabetes, glycemic control is important in preventing the development of microvascular complications, and glucagon-like peptide 1 receptor agonists may help reduce albuminuria levels. Other strategies include correcting metabolic acidosis, maintaining ideal body weight, following diets that are low in sodium and animal protein, and avoiding potential nephrotoxins such as nonsteroidal anti-inflammatories, proton-pump inhibitors, and iodinated contrast.Complete author and article information provided at end of article.

Evidence for Cardiorenal Protection with SGLT-2 Inhibitors and GLP-1 Receptor Agonists in Patients with Diabetic Kidney Disease

“…Despite the fact that treatment with SGLT-2 inhibitors is typically well-tolerated, physicians should be aware of some side effects associated with their use in daily clinical practice [6,12]. Genital fungal infection is by far the most commonly reported side effect of SGLT-2 inhibitors.…”

“…As in the case of SGLT-2 inhibitors GLP-1 receptor agonists represent an incretin-based class of anti-diabetic medications that also protect the heart and the kidney, a pleiotropic action that can only partially be explained by the treatment-induced improvement in glycemic control [6,12,31]. GLP-1 receptor agonists are effective in improving several cardiometabolic risk factors, inducing a reduction in body weight, small decreases in systolic BP, and improvement in serum lipid profile [6,12,31].…”

“…As in the case of SGLT-2 inhibitors GLP-1 receptor agonists represent an incretin-based class of anti-diabetic medications that also protect the heart and the kidney, a pleiotropic action that can only partially be explained by the treatment-induced improvement in glycemic control [6,12,31]. GLP-1 receptor agonists are effective in improving several cardiometabolic risk factors, inducing a reduction in body weight, small decreases in systolic BP, and improvement in serum lipid profile [6,12,31]. With respect to their renoprotective properties, experimental studies have shown that the GLP-1 receptor is expressed in glomerular, tubular, and vascular cells, generating, therefore, the hypothesis that these drugs may act by directly inhibiting the mechanisms that promote the injury to the diabetic kidney.…”

“…From the early 1990s and thereafter, optimal glycemic and blood pressure (BP) control have been two fundamental components of standard-of-care treatment for patients with T2DM and CKD [6,7]. In 2001, two landmark trials, the IDNT (Irbesartan Diabetic Nephropathy Trial) and RENAAL (Reduction of Endpoints in NIDDM with the Angiotensin II Antagonist Losartan), demonstrated that compared with placebo (in IDNT) or activetreatment with a calcium-channel-blocker (in RENAAL), an angiotensin-receptor-blocker was more effective in slowing the progression of CKD in patients with T2DM and overt nephropathy [8,9].…”

Impaired kidney function >90 days determines long‐term kidney outcomes

“…Nonetheless, early use of angiotensin-converting enzyme inhibitors or angiotensin-2 receptor blockers slow the progression of CKD. 25 As outlined above, once nephron loss begins, no new organoids can be formed. 26 For now, the most important next question is how we can reduce the risk of…”