How Chronic Kidney Disease Is Treated

From Diet and Drugs to Dialysis and Transplant

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Chronic kidney disease (CKD) is defined as the progressive and irreversible damage to the kidneys that, over the course of months or years, can lead to kidney (renal) failure. While there is no cure for CKD, there are treatments that can significantly slow the progression of the disease if started early.

The treatment can vary based on your stage of disease and the underlying cause, such as diabetes or high blood pressure.

Treatment options may include a low-protein diet, antihypertensive and statin medications, diuretics, vitamin supplements, bone marrow stimulants, and calcium-reducing drugs.

If the disease progresses and the kidneys are no longer functioning—a condition known as end-stage renal disease (ESRD)—either dialysis or a kidney transplant would be needed for you to survive.

Diet

CKD differs from an acute kidney injury (AKI) in that the latter is often reversible. With CKD, any damage done to the kidneys will be permanent. When damaged, fluids and waste normally excreted from the body in urine will "back up" and accumulate to increasingly harmful levels. Much of the waste is the result of the normal metabolism of protein.

Because CKD is progressive, immediate dietary changes would be needed to restrict your intake of protein and substances even if have no symptoms. If the disease progresses and kidney function is further impaired, there may be additional restrictions to your diet.

The dietary guidelines would be based on the stage of disease, which ranges from stage 1 for minimal impairment to stage 5 for ESRD. In addition, you would need to achieve your ideal weight while maintaining the recommended daily nutritional goals outlined in the 2015-2020 Dietary Guidelines for Americans.

It is usually best, particularly in the early stages, to work with a certified dietician to tailor a diet appropriate to your kidneys. Future consultations may also be recommended if and when your disease progresses.

Recommendations for All Stages of CKD

The goals of a CKD diet are to slow the progression of the disease and minimize any harm the accumulation of waste and fluids can do to other organs, most predominately the heart and cardiovascular system.

To this end, you would need to immediately adjust your diet in three key ways:

  • Reduce your sodium intake. According to the current guidelines, you should consume no more than 2,300 milligrams (mg) of sodium per day for adults and no more than 1,000 to 2,200 mg for children and teens. If you are African American, have high blood pressure, or are over 50, you would need to further restrict your intake to 1,500 mg daily.
  • Limit the intake of protein. The amount can vary based on the stage of disease. The current recommendation for people with stage 1 to stage 4 CKD is 0.6 to 0.75 grams of protein per kilogram of body weight per day, which broadly translates to:
Body weight (pounds)Daily protein intake (grams)Calories
10025-271,600
12531-342,000
15038-412,400
17544-472,800
  • Choose heart-healthy foods. The number one cause of death in people with ESRD is cardiac arrest. To this end, many kidney specialists (nephrologists) will endorse the use of a DASH (Dietary Approaches to Stop Hypertension) diet which focuses on portion control, getting the right amount of daily nutrients, and eating a variety of heart-healthy foods.

Recommendations for Stages 4 and 5 CKD

As the disease progresses and your renal function drops below 70 percent of what it should be, your nephrologist will recommend a restriction of phosphorus and potassium, two electrolytes that can harm the body if they accumulate excessively.

Among the considerations:

  • Phosphorus is important to the body as it helps to convert the foods we eat into energy, aids in bone growth and muscle contraction, and regulates blood acidity. If you have too much, it can lead to a condition known as hyperphosphatemia which can damage the heart, bones, thyroid gland, and muscles. To avoid this, adults with stage 4 to 5 CKD would need to restrict their daily intake to 800 to 1,000 mg per day by cutting back on phosphorus-containing foods.
  • Potassium is used by the body to regulate the heart rate and balance of water in cells. Having too much can lead to hyperkalemia, a condition characterized by weakness, nerve pain, abnormal heart rate, and, in some cases, heart attack. To avoid this, you would need to eat on a low-potassium diet, consuming no more than 2,000 mg per day.

OTC Supplements

A number of over-the-counter (OTC) supplements are commonly used to correct nutritional deficits that can occur in later stages of CKD. Among the recommended supplements:

  • Vitamin D and calcium supplements are sometimes needed to prevent the softening of bones (osteomalacia) and reduce the risk of bone fractures caused by a phosphorus-restricted diet. An active form of vitamin D, called calcitriol, may also be used, although it is only available by prescription.
  • Iron supplements are used to treat anemia common in stage 3 and stage 4 CKD. By stages 4 and 5, prescription-strength parenteral iron, delivered intravenously, may be used in people who don't respond to oral therapy.

Prescriptions

Prescription medications are commonly used to manage the symptoms of CKD or prevent later-stage complications. Some aid in reducing anemia and hypertension, while others are used to normalize the balance of fluids and electrolytes in the blood.

ACE Inhibitors

Angiotensin-converting enzyme (ACE) inhibitors are used to relax blood vessels and reduce high blood pressure. They can be prescribed at any stage of the disease and are used on an ongoing (chronic) basis to reduce cardiovascular risk.

Commonly prescribed ACE inhibitors include:

  • Accupril (quinapril)
  • Aceon (perindopril)
  • Altace (ramipril)
  • Capoten (captopril)
  • Lotensin (benazepril)
  • Mavik (trandolapril)
  • Monopril (fosinopril)
  • Prinivil (lisinopril)
  • Univasc (moexipril)
  • Vasotec (enalapril)

Side effects include dizziness, cough, itchiness, rash, abnormal taste, sore throat, irregular heartbeat, and swelling of the lower extremities.

Angiotensin II Receptor Blockers

Angiotensin II receptor blockers (ARBs) function similarly to ACE inhibitor but target a different enzyme to reduce blood pressure. ARBs are typically used in people who cannot tolerate ACE inhibitors.

Options include:

  • Atacand (candesartan)
  • Avapro (irbesartan)
  • Benicar (olmesartan)
  • Cozaar (losartan)
  • Diovan (valsartan)
  • Micardis (telmisartan)
  • Teveten (eprosartan)

Side effects include dizziness, diarrhea, muscle cramps, weakness, sinus infection, leg or back pain, insomnia, and irregular heartbeat.

Statin Drugs

Statin drugs are used to lower cholesterol and reduce the risk of cardiovascular disease. As with ARBs and ACE inhibitors, they are used on an ongoing basis.

The statin drugs commonly prescribed to treat high cholesterol (hypercholesterolemia) include:

  • Crestor (rosuvastatin)
  • Lescol (fluvastatin)
  • Lipitor (atorvastatin)
  • Livalo (pitavastatin)
  • Mevacor (lovastatin)
  • Pravachol (pravastatin)
  • Zocor (simvastatin)

Side effects include headache, constipation, diarrhea, rash, muscle aches, weakness, nausea, and vomiting.

Erythropoietin-Stimulating Agents

Erythropoietin (EPO) is a hormone produced by the kidneys that direct the production of red blood cells. When the kidneys are damaged, the output of EPO can drop significantly, causing chronic anemia. Erythropoietin-stimulating agents (ESAs) are injectable, man-made versions of EPO which help restore the red blood cell count and relieve the symptoms of anemia.

There are two ESAs currently approved for use in the U.S.:

  • Aranesp (darbepoetin alfa)
  • Epogen (epoetin alfa)

Side effects include injection site pain, fever, dizziness, high blood pressure, and nausea.

Phosphorus Binders

Phosphorus binders, also known as phosphate binders, are often used in people with stage 5 CKD to reduce levels of phosphorus in the blood. They are taken orally before a meal and prevent the body from absorbing phosphorus from the foods you eat. There are different forms available, some of which use calcium, magnesium, iron, or aluminum as the binding agent.

Options include:

  • Amphogel (aluminum hydroxide)
  • Auryxia (ferric nitrate)
  • Fosrenol (lanthanum carbonate)
  • PhosLo (calcium acetate)
  • Renagel (sevelamer)
  • Renvela (sevelamer carbonate)
  • Velphoro (sucroferrric oxyhydroxide)

Side effects include loss of appetite, upset stomach, gas, bloating, diarrhea, constipation, fatigue, itching, nausea, vomiting, and joint pain.

Diuretics

Diuretics, also known as "water pills," are used to remove excess water and salt (sodium chloride) from the body. Their role in treating CKD is twofold: to alleviate edema (the abnormal accumulation of fluid in tissue) and to improve heart function by reducing your blood pressure.

When treating early-stage CKD, doctors will often use a thiazide diuretic which can be used safely on an ongoing basis. Options include:

  • Diuril (chlorothiazide)
  • Lozol (indapamide)
  • Microzide (hydrochlorothiazide)
  • Thalitone (chlorthalidone)
  • Zaroxolyn (metolazone)

Another more potent form of the drug, called a loop diuretic, may be prescribed in stage 4 and stage 5 CKD, especially if you are diagnosed with chronic heart failure (CHF). Options include:

  • Bumex (bumetanide)
  • Demadex (torsemide)
  • Edecrin (ethacrynic acid)
  • Lasix (furosemide)

Common side effects of diuretics include thirst, dry mouth, headache, dizziness, and muscle cramps.

Dialysis

Stage 5 CKD is the stage by which renal function has dropped below 10 or 15 percent. At the stage, without aggressive medical intervention, the accumulated toxins can cause multiple organs to fail, leading to death in anywhere from hours to weeks.

One such intervention is called dialysis. This involves the mechanical or chemical filtering of waste and fluids from your blood when your kidneys are no longer able to do so. There are two methods commonly used for this, known as hemodialysis and peritoneal dialysis.

Hemodialysis

Hemodialysis uses a mechanical filtration machine to purify blood taken directly from a blood vessel and returned to your body in a clean and balanced state. It can be performed at a hospital or dialysis center. Newer portable models are available which allow you to undergo dialysis at home.

The process begins with a surgical procedure to create an access point from which to draw and return blood from a vein or artery. There are three ways to do this:

  • Central venous catheterization (CVC) involves the insertion of a flexible tube into a large vein, such as the jugular or femoral vein. This is usually the first technique used before a more permanent access point can be created.
  • Arteriovenous (AV) fistula surgery involves the joining together of an artery and vein, usually in the forearm. This allows needles to be inserted into the access point to simultaneously retrieve and return blood. Once performed, you would need to wait four to eight weeks before hemodialysis can begin.
  • AV grafts work in much the same way as an AV fistula except that an artificial vessel is used to join the artery and vein. While an AV graft heals faster than an AV fistula, they are more prone to infection and clotting.

Hemodialysis requires you to visit the hospital or clinic three times a week for four-hour sessions. While the home dialysis machine can offer you privacy and convenience, it requires six treatments per week at 2-1/2 hours each.

There is another home option, known as nocturnal daily hemodialysis, in which the cleansing of blood is done while you sleep. It is performed five to seven times per week, lasting six to eight hours, and may afford you the greater clearance of waste compared to the other versions.

Side effects of hemodialysis include low blood pressure (hypotension), shortness of breath, abdominal cramps, muscle cramps, nausea, and vomiting.

Peritoneal Dialysis

Peritoneal dialysis uses chemicals rather than machinery to cleanse your blood. It involves the surgical implantation of a catheter into your abdomen through which a liquid solution, called dialysate, is fed to absorb waste and draw out accumulated fluids. The solution is then extracted and discarded.

The dialysate solution is typically composed of salt and an osmotic agent like glucose which inhibits the reabsorption of water and sodium. The membrane that lines the abdominal cavity, called the peritoneum, serves as the filter through which fluids, electrolytes, and other dissolved substances can be extracted from the blood.

Once the catheter is implanted, the dialysis can be performed at home several times per day. For each treatment, two to three liters of solution would be fed into your belly through the catheter and kept there for four to six hours. Once the waste solution is drained, the process is started all over again with fresh dialysate solution.

Automated cycling machines can perform this task this overnight, providing you greater independence and time to pursue everyday interests.

Complications of peritoneal dialysis include infection, low blood pressure (if too much fluid is extracted), abdominal bleeding, and bowel perforation. The procedure itself can cause abdominal discomfort and impaired breathing (due to the increased pressure placed on the diaphragm).

Kidney Transplant

A kidney transplant is a procedure in which a healthy kidney is taken from a live or deceased donor and surgically implanted into your body. While it is a major surgery fraught with short- and long-term challenges, a successful transplant can not only extend your life but restore you to a near-normal state of function.

With that being said, the results can vary from person. While you will no longer require dialysis or the same dietary restrictions, you will need to take immune suppressive drugs for the rest of your life to avoid organ rejection. This can increase the risk of infection, requiring you to take extra steps to avoid illness and treat infections aggressively.

People with stage 5 CKD can get a transplant at any age, whether they are a child or senior. However, you would need to be healthy enough to withstand the operation and must be free from cancer and certain infections.

What to Expect

To assess your eligibility, you would have to undergo physical and psychological evaluation. If a problem is found, it would need to be treated or corrected before the transplant is improved.

Once approved, you would be placed on a waiting list managed by the United Network of Organ Sharing (UNOS). Of all of the organ transplant types, a kidney transplant has the longest waiting list with an average wait time of five years. You will be prioritized based on how long you've been waiting, your blood type, your current health, and other factors.

Once a donor kidney has been found, you would be scheduled and prepped for surgery. In most cases, only one kidney would be transplanted without removing the old ones. You would generally be well enough to return home after a week.

Once transplanted, it can take up to three weeks for the new organ to be fully functional. During this time would need to continue dialysis.

Thanks to advances in transplant surgery and management, kidney recipients can expect to live for between eight to 12 years if the donor was deceased and 12 to 20 years if the donor was living.

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