Clinical Edge

Summaries of Must-Read Clinical Literature, Guidelines, and FDA Actions

Management of Chronic Kidney Disease

A practical guide for clinicians

This guideline for the practical approach of chronic kidney disease (CKD) was developed for the primary care physician to guide assessment and care of chronic kidney disease. Recommendations include:

• Assessment of estimated glomerular filtration rate 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 (ACE-1) or angiotensin receptor blockers (ARB) for patients with albuminuria and hypertension, hemoglobin A1C < 7% for patients with diabetes, and correction of CKD-associated metabolic acidosis.

• Avoidance of nephrotoxic drugs including NSAIDs, and be aware to use reduced doses of medications that are renally excreted, such as insulin, many antibiotics, and some statins.

The ultimate goal of chronic kidney disease management is to prevent disease progression, minimize complications, and promote quality of life.

Citation: Vassalotti JA, Centor R, Turner BJ, Greer RC, Choi M, Sequist TD, and the 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. [Published online ahead of print September 25, 2015]. doi: 10.1016/j.amjmed.2015.08.025.

Commentary: Over 10% of the US population has CKD, defined as a GFR < 60ml/min/1.73m2 and/or abumin-creatinine ratio >30mg/g. Both GFR and albuminurea independently predict progression of CKD. Control of blood pressure, use of an ACE or an ARB, and control of A1C are well-appreciated methods of slowing progression of CKD. It is not as well appreciated that ACE and ARB treatment 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 should be added 3 times daily to raise the bicarbonate above 22 mmol/L. For patients with severe CKD, referral to a nephrologist is appropriate. —Neil Skolnik, MD

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