The use of angiotensin-converting enzyme (ACE) inhibitors or an- giotensin-receptor blockers (ARBs) is recommended as tolerated, as these medications have been shown to decrease the risk of long-term dialysis and mortality. Patients must be closely moni- tored for kidney disease progression and hyperkalemia, a known side effect of these two classes of medication. A small increase in serum creatinine levels is common with ACE inhibitors and ARBs, but if an increase of more than 30% occurs within four weeks of starting or increasing the dose, these medications should be stopped. Patients with advanced renal failure or renal artery ste- nosis should avoid these medications (KDIGO Work Group, 2021). Case study, continued While at her checkup appointment with her primary care provider, Sally discusses her blood pressure control with her doctor. She has a preexisting diagnosis of high blood pressure but stopped tak- ing her blood pressure medication because she was experiencing side effects. Her doctor wants to start her on a new agent to get her blood pressure under control and prevent the progression of her chronic kidney disease. Sally agrees to this and wants the best medication that will prevent long-term complications. Avoiding nephrotoxic medications A frequent cause of worsening kidney function is the adminis- tration of medications that adversely affect renal function. Med- ications to avoid in patients with chronic kidney disease include (Rosenberg, 2021): ● Aminoglycoside antibiotics, such as gentamycin. ● Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibu - profen and meloxicam. ● IV contrast dye used in certain MRI and CT scans. Protein restriction Since excess dietary protein intake can lead to the accumulation of waste products in the body, the KDIGO Work Group recom- mends reducing protein intake to 0.8 g/kg/day in patients with GFR less than 30 mL/min/1.73m 2 and avoiding high-protein diets that include more than 1.3 g/kg/day in early-stage CKD patients at risk of progression. Restricting dietary protein must be done cautiously because insufficient protein intake can decrease lean Renal diet Patients with chronic kidney disease may need to make changes to their diet to prevent disease progression. A reduction in salt intake can aid in slowing the progression of chronic kidney dis- ease, in part by helping to lower blood pressure, a significant risk factor for disease progression. Hypertensive, volume overloaded, or proteinuric patients with a GFR of less than 60 mL/min/1.73m 2 may benefit from reducing sodium intake to less than 2 grams per day (Rosenberg, 2021). Renal replacement therapy (Dialysis) There are a number of clinical indicators that show dialysis may be necessary in a patient with severe chronic kidney disease. While there is not a specific GFR at which dialysis should be initiated, it is common for clinical signs and symptoms of kidney failure to occur when the GFR is between 5 and 10 mL/min/1.73m 2 . Clini- cal indicators used to determine when to initiate dialysis include (Rosenberg, 2021): ● Pericarditis or pleuritis. ● Progressive uremic neuropathy or encephalopathy, exhibited by confusion, myoclonus, foot or wrist drop, or seizures. ● Clinically significant bleeding attributable to uremia. ● Fluid overload that is refractory to diuretics. ● Evidence of malnutrition. ● High blood pressure that is poorly responsive to antihyperten- sive agents. ● Persistent nausea and vomiting.
Since hypertension in CKD is often related to volume expansion, diuretics are recommended to remove excess fluids and reduce the patient’s weight to their “dry weight,” or their normal weight without edema. Thiazide diuretics such as chlorthalidone and loop diuretics such as furosemide are recommended for this purpose. Thiazide diuretics are not typically used to treat hypertension and edema in CKD patients because their effectiveness decreases when the estimated GFR falls below 30 mL/min/1.73m 2 , though some agents such as chlorthalidone appear to remain effective at lower GFRs. Loop diuretics are more commonly used in patients with GFRs of less than 30 mL/min/1.73m 2 due to their effective- ness (KDIGO Work Group, 2021).
Self-Assessment Quiz Question #5 Which of the following blood pressure medications would de- crease Sally’s risk of long-term dialysis and mortality?
a. Metoprolol. b. Amlodipine. c. Diltiazem. d. Lisinopril.
Many other medications may be considered potentially nephro- toxic but may not require strict avoidance in chronic kidney dis- ease patients. Oftentimes, when dosed appropriately and closely monitored, potentially nephrotoxic medications can be used safe- ly in early-stage CKD patients. References should be consulted prior to initiating new medications in CKD patients to ensure ap- propriate medications are used at appropriate dosages to prevent nephrotoxicity and adverse effects (DiPiro et al., 2019). body mass and lead to malnutrition. Advanced chronic kidney dis- ease is associated with protein wasting syndrome, which causes increased morbidity and mortality, so protein restriction may be inappropriate in late-stage patients. Dietary changes should be patient-specific and target individual goals (KDIGO Work Group, 2013). Other dietary restrictions may be indicated depending on the patient. Fluid restriction can be used in patients with edema to reduce or avoid fluid overload. Phosphorus restriction to less than 0.8 to 1 gram per day is often recommended, since some studies suggest dietary phosphorus can alter fibroblast growth factor pro - duction, which affects serum phosphate concentrations. Potassi- um restriction is typically reserved for hyperkalemic patients (Cho & Beddhu, 2021). ● Persistent, refractory metabolic disturbances such as metabol- ic acidosis, hyponatremia, hyperkalemia, hyper- or hypocalce- mia, and hyperphosphatemia. Relative indications for initiating dialysis include decreased cog- nition, persistent pruritis, depression, and restless leg syndrome. Asymptomatic patients may require dialysis when their GFR reach- es low levels, such as less than 10 mL/min/1.73m 2 , to prevent the development of potentially life-threatening complications of ure- mia. Some providers choose to monitor these patients frequently, such as weekly, and plan to initiate dialysis when symptoms of uremia develop. Other factors may influence the choice to initiate dialysis, including the rate of renal function decline and life expec- tancy (Rosenberg, 2021).
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