HOW TO TREAT 31 and hyperkalaemia potentially limits its utilisation in patients with CKD , and management of such cases may be best undertaken in specialist centres under close supervision .
ausdoc . com . au 8 NOVEMBER 2024
HOW TO TREAT 31 and hyperkalaemia potentially limits its utilisation in patients with CKD , and management of such cases may be best undertaken in specialist centres under close supervision .
Intensive lipid lowering therapy
All patients with high blood pressure and CKD are at increased risk of heart attack or stroke . This risk can be reduced by lowering their circulating LDL cholesterol concentration , regardless of their baseline concentration of LDL cholesterol , and in proportion to the degree of LDL cholesterol lowering achieved . Guidelines recommend that all people with high blood pressure and CKD are treated with a high potency statin in the highest dose tolerated by that individual . 30 , 31 Where residual cardiovascular risk remains high ( eg , in patients with proteinuria or established CVD ), consider the additional use of ezetimibe . For example , in the Study of Heart and Renal Protection trial , treatment with simvastatin and ezetimibe was associated with lowered cardiovascular events in non-dialysis patients with CKD when compared with simvastatin alone . 32 However , lipid lowering did not slow the decline in kidney function or prevent kidney failure . 32
SGLT-2 inhibition
Treatment with SGLT-2 inhibitors lowers the risk of declining kidney function and kidney failure in people with CKD . 33 The benefits to the kidney are independent of the actions of SGLT-2 inhibitors on glucose control , blood pressure or weight . Current guidelines recommend all people with CKD at increased risk of kidney failure are considered as candidates for SGLT-2 inhibition , including non-diabetic individuals with high blood pressure and CKD . 2 , 17 , 34 In Australia , both dapagliflozin 10mg and empagliflozin 10mg are included on the PBS to reduce the risk of kidney disease progression in high-risk patients with CKD : those individuals with an eGFR of 25-75mL / min / 1.73m 2 and an elevated urine ACR of ( 30mg / g or greater ), who have been stable using an ACEI or ARB ( unless contraindicated ) for at least four weeks .
Non-steroidal mineralocorticoid receptor antagonists
Non-steroidal MRAs have been shown to reduce albuminuria and slow kidney function decline when added to standard of care in patients with CKD . 35 In Australia , finerenone is indicated to delay progressive decline of kidney function in adults with type 2 diabetes , CKD and elevated urinary albumin excretion . There is currently no indication for non-diabetic kidney disease , although MRAs may be indicated for their antihypertensive actions or treatment of concomitant heart failure in this setting . All MRAs , including newer non-steroidal MRAs , may be associated with hyperkalaemia , AKI and hypotension , so must be introduced and titrated cautiously , with close monitoring , especially in patients with CKD .
GLP-1 receptor agonists
Obesity can be an important driving factor for the development and progression of high blood pressure and CKD in some individuals . 36 Treatment with GLP-1 receptor agonists ( GLP-1 RAs ) in people with obesity is associated with a reduction in albuminuria and a lower incidence of significant kidney function decline . 37 A placebo-controlled randomised controlled trial of treatment with semaglutide in patients with type 2 diabetes and CKD was recently stopped early due to unequivocal evidence of kidney benefit . 38 Although GLP-1 RAs are not currently indicated for the protection of kidney function , the holistic management of patients with obesity should prioritise early and sustained significant weight loss that can be achieved with GLP-1 RAs , when used appropriately .
Avoiding superimposed insults to the kidney
In CKD , the function of the kidneys sometimes declines in a stepwise fashion , with periods of relative stability punctuated by episodes of more rapid decline . The latter can be precipitated by superimposed insults such as dehydration , hypoperfusion , fluid overload , infection or drug toxicity ( eg , contrast agents , chemotherapy , NSAIDs , aminoglycosides and certain herbal medicines ). 2 , 17 Sick day rules when to pause medication use ( eg , before surgery , when not eating or drinking because of illness ) are highly relevant in the setting of CKD , including pausing RAAS blockade , diuretic use , SGLT-2 inhibition and metformin treatment , when appropriate , to reduce the risk of AKI . 2 , 17
Lifestyle interventions
Individuals with obesity and CKD can benefit from significant weight loss . 39 Encourage patients to undertake regular physical activity , ideally 150 minutes of moderate intensity exercise per week . It is also recommended that patients with high blood pressure and CKD aim to reduce their salt intake to less than 5g / day ( less than 2g of sodium per day ). 39 This can improve blood pressure control , reduce oedema and reduce albuminuria in combination with standard care , including RAAS blockade . Increased potassium consumption , preferably via dietary modification , is generally recommended for adults with elevated blood pressure . 40 However , already high plasma potassium concentrations in patients with CKD , and their treatment with RAAS inhibitors may make this impractical for most patients with CKD . Instead many patients have to moderate their intake of ( potentially
In adults with chronic kidney disease :
beneficial ) potassium rich foods to prevent hyperkalaemia . 2 , 17
Regular review and re-evaluation
Regular review and continuity of care from the same GP increases the
Check the blood pressure , perform a blood test to measure eGFR and potassium
Systolic blood pressure > 110mmHg and potassium < 5.0mEq and eGFR > 30mL / min / 1.73m 2
Offer an ARB or ACEI * Initiate at the lowest dose with the aim to titrate to the highest licensed dose that the person can tolerate Consider using a fixed-dose combination if already on other blood pressure lowering agents
1-2 weeks after initiation of therapy or each dose change check the blood pressure , perform a blood test to measure eGFR and potassium
Blood pressure > 110mmHg and potassium < 5mEq and eGFR decrease < 25 %
Increased dose or continue , if on maximal tolerated dose
Systolic blood pressure < 110mmHg or potassium > 5.0mEq or eGFR < 30mL / min / 1.73m 2
Hypotension or potassium > 5mEq or eGFR decrease > 25 %
Person has CKD
Is blood pressure consistently below target (< 130 / 80 mmHg )? Consider using Ambulatory Blood Pressure Monitoring ( ABPM ) and / or Home Blood Pressure Monitoring ( HBPM )
Yes
• Continue to monitor blood pressure
• Manage lifestyle risk factors
Yes
Yes
Is blood pressure consistently below target ?
No
• Start ACE inhibitor or ARB
• Monitor eGFR and K +
• Continue to monitor blood pressure ( consider home monitoring )
• Manage lifestyle risk factors
• Encourage medication and lifestyle adherence
• Increase ACE inhibitor or ARB to maximum recommended dose
• Consider adding : calcium channel blocker , or diuretic , or beta blocker
• Refer to nephrologist if blood pressure is not consistently below target with at least 3 anti-hypertensive agents
Is blood pressure consistently below target ?
Figure 8 . Algorithm for management of high blood pressure in chronic kidney disease ( CKD ).
No
No
likelihood of achieving target blood pressure . 41 Regular measurement of eGFR is appropriate in all people with CKD ; perform this routinely at least every 3-6 months , as well as during any intercurrent illnesses , as all people with reduced kidney function are
Assess and treat potential causal factors
Do not initiate if mitigation unsuccessful
Consider support and / or referral
Assess and treat potential causal factors
Reduce the dose or stop if mitigation is unsuccessful
Consider support and / or referral
Figure 9 . The initiation and titration of agents that block the renin angiotensin aldosterone system in patients with chronic kidney disease .
Chronic Kidney Disease Management in Primary Care ( 5th edition ). Kidney Health Australia , Melbourne , 2024 17
* Unless other contraindications :
See product information for further details .