Chronic kidney disease (CKD) is irreversible and characterized by its progressive nature. There are treatment and management options available that both providers and patients can take to help slow CKD disease progression. Another factor that affects the progression of CKD is the delivery of care that a patient receives. Panoramic Health is the leader in integrated value-based care, designed and coordinated to provide customized treatments and interventions for each patient, which has been shown to help slow CKD progression.
Value-based care and care coordination allow patients with CKD to not only live longer with associated complications, but also have an improved quality of life through reduced hospitalizations, appropriate dialysis start times, and the delay or potential prevention of end-stage kidney disease (ESRD).
Overview of Chronic Kidney Disease
More than 1 in 7 or 15% (37 million) of adults in the United States are estimated to have chronic kidney disease (CKD).
Chronic kidney disease (CKD) is a condition of the kidneys that is characterized by the gradual loss of kidney function over a period of time due to damage. The kidneys are no longer able to filter blood as effectively as healthy kidneys. Excess fluid and waste are thus not able to be appropriately disposed of and remain in the body. This may lead to other health problems (i.e., stroke, heart disease, increased occurrence of infections).
The main causes of CKD
It is reported that hypertension (high blood pressure) and diabetes are responsible for around two-thirds of chronic kidney cases. Hypertension (high blood pressure) is characterized by the increase of blood pressure against the walls of the body’s blood vessels. If left uncontrolled or not adequately controlled, this may result in an increased risk of strokes, heart attacks, and chronic kidney disease. It is important to note that CKD can also cause hypertension. Diabetes is characterized by high blood sugar levels over a period of time that results in damage to the kidneys, eyes, nerves, blood vessels, and heart.
Symptoms and Diagnosis
The only way to diagnose CKD is through specific urine and blood tests; this is due to CKD not displaying any significant symptoms in patients. The tests used to diagnose CKD are often used to measure a patient’s protein level in the urine and creatine levels in the blood. Glomerular filtration rate (GFR) will also be calculated by your doctor, and it is one of the better ways to measure the patient’s level of kidney function and stage of kidney disease. Additional tests may be required by your physician.
Impact of CKD Progression
In most cases of CKD, it is a silent disease that only starts presenting with noticeable symptoms when it reaches stages 3 to 5, as kidney function has become severely decreased. This decreased function of the kidneys has the potential to cause significant health issues to all other body systems. There is also an increased financial burden to both the patient and payer the further CKD progresses.
Treatment Strategies in Slowing the Progression of Chronic Kidney Disease
Before we discuss the different treatment strategies that are available to help slow CKD progression, it is important to note that early detection of CKD is the first step in helping prevent the progression of kidney disease to kidney failure, as well as an interdisciplinary approach is needed for each patient and the complications of their CKD.
The treatment strategies to slow the progression of chronic kidney disease include:
- Nutritional Intervention
- Lifestyle Interventions
- Medical Management
Nutritional Interventions
The kidneys play an important role in the metabolism of nutrients, with patients that have CKD losing the ability to maintain homeostasis and excrete solutes. Patients with advanced-stage kidney disease are unable to maintain sufficient nutrient homeostasis and can develop metabolic disorders such as hyperkalemia, metabolic acidosis, inflammation, altered hormone regulation, as well as sodium and volume overload.
Nutritional intervention is essential to slow disease progression and is a central component of patient care.
Diet therapy (nutritional interventions) in CKD are two-fold:
- To slow the progression
- Treat and prevent any complications that may occur (i.e., malnutrition)
The first step in diet therapy is to lower or limit dietary sodium to 2,300mg/day, to help control blood pressure. If the patient is taking medications that block the renin-angiotensin-aldosterone system (RAAS), then salt substitutes that are rich in potassium should be avoided.
The second step is to ensure that the patient is getting adequate protein and not excessive protein intake. The adequate protein intake calculation is 0.8 g/kg body weight/day and may help to reduce albuminuria. Albuminuria is a sign of kidney disease and is characterized by excess albumin (a protein found in the body) in the urine. As CKD progresses in a patient, dietary potassium or phosphorus may need to be limited.
It is vital that a patient consults with a dietitian that can assess and begin an individualized medical nutrition therapy (MNT). Panoramic Health offers a comprehensive care model that includes nutrition services.
Lifestyle Interventions
Patients diagnosed with CKD are encouraged to make certain lifestyle changes where applicable, such as:
- Quitting smoking
- Becoming more active (increasing physical activity)
- Losing weight if you are overweight
- Using medications as directed
- Improving healthy eating (consulting with a dietitian)
Patients who smoke cigarettes are at risk of having abnormal urine albumin and increasing the progression of their CKD, as well as increasing their risk of suffering from a fatal heart attack or stroke. Patients quitting cigarette smoking can utilize step-down nicotine replacement therapy but will need to be monitored for potential side effects such as contact allergy or sensitization or worsening of existing hypertension.
Patients are encouraged to exercise for at least 20-30 minutes every day and also prevent deconditioning or increase deconditioning through strength and aerobic training. Physical activity is known to potentially help improve glucose levels (those with diabetes), maintain muscle mass, and may prevent cardiovascular disease.
It has been shown that patients with chronic diseases that have been provided with self-management education present with improved health status and health behaviors.
Medical Management
Medical management involves key interventions to control blood pressure and blood glucose levels in those with diabetes and induce (with ARBs or ACE inhibitors) a blockade of the renin-angiotensin-aldosterone system (RAAS).
Medical management methods for slowing CKD progression:
Reduce albuminuria levels in the urine. Increased or excessive levels of albumin (a protein found in the body) are associated with an increased risk of chronic kidney disease or decreased renal function. Research has shown that decreasing the levels of albumin in the urine may decrease the risk of CKD progression. Medications ACE inhibitors and ARBs may slow the progression of CKD as they work to lower glomerular capillary blood pressure and systemic blood pressure.
Blood glucose control for diabetic patients. Individualized therapeutic goals are essential for successful maintenance and achievement of glucose control in the patient. The control of glucose levels in those with diabetes has shown to potentially reduce the risk of developing patient albuminuria. In patients with type 1 diabetes, the strict control of blood glucose levels was shown to slow the progression of albuminuria. The positive effects on CKD progression in patients with type 2 diabetes are unknown and need further studies conducted.
Blood pressure control. Hypertension (high blood pressure) is a known cause and complication of chronic kidney disease, and when left uncontrolled, it can increase the loss of GFR and is a leading cause of an increased decline in renal function, which leads to ESRD (end-stage renal disease). Hypertension is typically controlled or decreased with a combination of lifestyle modifications (diet, exercise, quitting smoking, etc.) and antihypertensive medications. Medications such as ARBs and ACE inhibitors have been shown to potentially slow CKD progression, specifically in patients that present with albuminuria; these medications are shown to also lower systemic blood pressure whilst lowering glomerular capillary blood pressure.
It is important that routine blood pressure monitoring occurs in patients with CKD, and effective treatment of hypertension occurs if required.
Delivery of CKD Care
The way care to CKD patients is delivered is known to affect the outcomes of patient health; for example, studies show that multidisciplinary CKD programs are linked to better patient outcomes, as they show better adherence to CKD guidelines and a higher incidence of early intervention (patients start dialysis earlier than those receiving emergency care).
Thus the value-based Kidney care that Panoramic Health is essential to the treatment of CKD, as it provides necessary care coordination that is shown to help lower costs, prevent hospitalizations, and improve a patient’s overall quality of life.
Conclusion
It is important to note that even though these treatments and management options are known to potentially help slow the progression of chronic kidney disease, not every patient will respond favorably to the measures discussed above. Thus, if disease progression occurs without slowing down, associated complications and comorbidity such as malnutrition, mineral and bone disorders, decreased functional status and depression, and cardiovascular disease is routinely monitored.
An interdisciplinary team and value-based care can be the difference in both increased disease progression and improved quality of life.
