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What Can Patients Do to Delay the Progression to Complete Kidney Failure?
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By Dean A. Kujubu, MD Your doctor has just informed you that you have chronic kidney disease (CKD). Rather than being a specific diagnosis, CKD means that your kidney function is not completely normal for someone of your age, gender, and race. In CKD, some of the filtering units of the kidneys are not functional. Because of that, the remaining filtering units are working "overtime" in a compensatory attempt to maximize kidney function. While this is helpful in the short run, continued overworking of the filtering units over time may lead to scarring and progressive failure. A vicious cycle is established as the remaining filtering units are forced to work even harder. If this cycle is not interrupted, CKD may lead to the need for dialysis treatment as kidney function worsens to the point of kidney failure. Your goal is to preserve the kidney function that you have and prevent the progression of CKD to the dialysis stage. Following these guidelines will help you stay healthy with CKD: Seeing a specialist whose focus is on kidney diseases should be the first step in dealing with your CKD. Several studies have demonstrated that patients with CKD who see a nephrologist early do better than those who see a nephrologist later. Nephrologists are focused on blood pressure (BP) and blood sugar control (diabetes and hypertension are the two leading causes of kidney disease), adjusting medications for the level of kidney function, and advising you on how you can best protect your kidneys. They can also help determine if there is a cause for CKD that is potentially reversible. The nephrologist often works with dietitians who can advise you regarding the proper diet to keep your kidneys healthy. The nephrologist will work hand-in-hand with your primary care physician to maintain your health. - Control your blood pressure.
High BP increases the pressure within the already strained filtering units of the kidney. Making sure it is controlled is essential in keeping your kidneys healthy. The target blood pressure in people with CKD should be 130/80 or below. If you have a lot of protein in your urine, the BP goal should be even lower, less than 125/75. It is unusual for BP to be controlled this well with one medication alone; often several medications are needed to accomplish this. Salt restriction, exercise, relaxation techniques, and weight loss along with medications all help in getting the BP under control. Certain medications are preferred in helping to achieve target BP control. Angiotensin converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) both reduce pressure within the filtering units and have been shown to slow the progression of CKD in both diabetic and non-diabetic patients. These medications are particularly important if you have a lot of protein in your urine. Occasionally, patients with CKD who are started on either ACEI or ARB medications develop high blood potassium levels or experience a marked fall in kidney function (>30%). Your physician will need to follow some simple blood tests after you start these medications. - Control your blood sugar.
If you have diabetes, getting your blood sugar under control will also help your kidneys. The goal is to get the sugar control during the day as close to normal as possible and a hemoglobin A1c of less than 7.0. The hemoglobin A1c is an index of how well your sugar has been under control over the past three months. In addition to medications, proper diet and exercise are essential in helping control blood sugar. Once again, ACEI and ARB medications help decrease the strain on the filtering units in patients due to diabetes and should be used if you also have high BP. Smoking is certainly not good for the lungs and the circulation. It is also not good for the kidneys, particularly in those with CKD. If you didn’t have enough reasons already to stop smoking, preserving kidney function can be added to the list of reasons to quit the habit. - Avoid medications and agents that can injure the kidneys.
Many medications are prescribed to treat kidney disease. As such, these organs are often first in line to feel the effects of new medications. Certain antibiotics, such as gentamicin, used for serious infections in the hospital setting, can injure the kidneys. Even over-the-counter medications can cause problems. Medications--such as non-steroidal anti-inflammatory drugs (NSAID), which include ibuprofen and naproxen, commonly used for pain--can compromise kidney function. Phosphate-containing laxatives and enemas have also been reported to rarely cause kidney problems. High doses of vitamin C have been associated with the development of kidney stones. Certain herbal medications have also been tied to kidney injury. If you are uncertain about your medications, your physician can help clarify things for you. Although they are not medications per se, injected contrast agents used for CT and magnetic resonance imaging (MRI) scans can be harmful to the kidneys if your renal function is already somewhat compromised. A careful discussion with your physician is important to discuss the risks versus benefits of receiving contrast injections. If the information gained from the test requires that a contrast agent be used, several precautionary measures can be taken to minimize injury to the kidneys prior to your exposure to that agent. Since many medications are handled by the kidneys, when renal function is not completely normal, some medication dosages may need to be adjusted. Discussing these dosages with a physician is important for anyone with CKD. Many of the poisons that the kidneys need to remove are related to breakdown products of protein. In animal studies, high protein intake causes kidney injury. Several studies in patients have sought to determine if reducing protein intake will reduce injury in the kidneys and help to preserve their function. Thus far, the results have been conflicting—some studies suggested benefit, others showed no difference from a regular diet. Most nephrologists, however, would recommend mild dietary protein restriction for those with CKD. Consultation with a dietitian accustomed to working with CKD patients is important if you are considering this option. Because patients with CKD are at risk for developing heart disease, it is reasonable to try to get your lipid profile under control. In addition, there is some evidence that those patients with better lipid panels have a slowing of their kidney disease. Getting the low density lipoprotein (LDL, or "bad" cholesterol) lower than 100 mg/dl and triglyceride level less than 200 mg/dl is a good start. Diet and exercise are important, but medications are also often needed to lower "bad" cholesterol levels. Conclusion A diagnosis of CKD today is certainly not an eventual "death sentence," as it may have been for most of those suffering from it only 35-40 years ago. It also does not necessarily mean eventual dialysis. I have outlined above several things you can do to ensure that you and your kidneys remain healthy. And remember that it is important to form a good partnership with your physician and renal healthcare team and remain informed about health issues so you can do all you can to stay as healthy as possible despite CKD. About the Author Dean A. Kujubu, MD, is Director of the Nephrology Fellowship program at the Kaiser Permanente Los Angeles Medical Center in Los Angeles, CA. He is also Clinical Assistant Professor of Medicine at the University of California, Los Angeles School of Medicine.
Last Updated January 2008
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