Treatment & Management
The following measures aim to treat the reversible causes of kidney didease, slow its progression, and treat complications.

• Control blood pressure; target less than 140/90 mmHg (Norton et al., 2017a).
• Treat with renin-angiotensin-aldosterone system (RAAS) blockers such as ACE inhibitors and ARBs for the following (KDIGO, 2012):
  • Albuminuria 30-300 mg/24 hours in diabetic adults
  • Albuminuria greater than 300 mg/24 hours in diabetic and nondiabetic adults
• Manage diabetes (KDIGO, 2012).
  • Target hemoglobin A1c to 7.0% or less than 7% (53 mmol/mol) to prevent or delay progression of diabetes complications
• Measure hemoglobin to monitor for anemia.
• Encourage smoking cessation.
• Encourage weight reduction.
• Temporarily discontinue nephrotoxic and renally excreted medications if GFR less than 60 mL/min/1.73m² and increased risk of AKI (KDIGO, 2012; Norton et al., 2017a) such as non-steroidal anti-inflammatory drugs (NSAIDS), diuretics, metformin, lithium, digoxin, quinolones, B-lactam antiobiotics, sulfonamides.

• Restrict salt intake (KDIGO, 2012).
  • Goal is less than 90 mmol (2 grams/day), unless contraindicated.
• Modify protein intake (KDIGO, 2012).
  • Reduce protein intake to 0.8 grams/kg body weight.
  • Avoid high protein intake (greater than 1.3 g/kg/day) in adults with CKD at risk of progression.
• Recommend high-calorie diet.
• Avoid foods high in potassium, phosphorus, and sodium.
• Restrict fluid intake based on urine production.

Kidney replacement therapy (KRT) (Norton et al., 2017b)

Hemodialysis

• Initiate when one or more of the following are present (KDIGO, 2012):
  • Signs or symptoms of kidney failure (serositis, acid-base or electrolyte abnormalities, pruritus)
  • Inability to control volume status or blood pressure
  • Progressive decrease in nutritional status unresponsive to dietary intervention
  • Cognitive impairment
• Dialyzer machine is used to filter waste products from the blood three or more times a week; diffusion efficacy depends on the dialysate solution.
• Vascular access required
  • Arteriovenous fistula: an artificial connection between an artery and vein diverting blood to the vein; preferred access method
  • Arteriovenous graft: second option if fistula cannot be created
  • In an emergency, temporary vascular access may be obtained in a central vein (i.e., internal jugular) however these are associated with inadequate dialysis, increased infection rates, clotting, and inflammation. 

• The peritoneal membrane is used as a semipermeable filter, replacing the kidneys. A dialysis solution (osmotic agent) is infused into the abdominal cavity through a percutaneous catheter. Through diffusion, waste products are pulled from the blood in the peritoneal capillaries into the dialysate. Following the prescribed dwell time, the solution is drained through the catheter.

• Efficacy is based on:
  • Concentration gradient
  • Size of the solute
  • Permeability of the peritoneal membrane
• Restrict potassium intake.
• Replace amino acids.
• Increase dietary proteins.
• Monitor glucose closely; insulin may be added to dialysis solution.

• Living donor renal transplantation should be considered when GRF is less than 20 mL/min/1.73m² and there is evidence of progressive and irreversible CKD over the preceding 6-12 months (KDIGO, 2012).

• Option for people who choose not to pursue KRT
• Advance care planning and end-of-life care
• Include protocols for dietary restrictions, symptom and pain management, psychological care, spiritual care, culturally sensitive care and bereavement support.