Treatment
Chronic kidney disease requires an interprofessional team to collaboratively work in the best interest of the patient. Collaboration is key to ensure all aspects of health (diet, medications, medical conditions, psychological status) of a patient with CKD are considered and optimized to ensure maximal health benefit.
Initially diet and medications are utilized to perserve kidney function and slow the progression to end-stage renal disease.
Diet
It is important to make changes in diet to compensate for the kidneys which are not properly functioning and cannot excrete certain food breakdown products. Certain dietary restrictions will prevent waste build-up and maintain balance. It is also important to ensure patients with CKD intake enough calories to prevent muscle breakdown. A dietician will review the important diet recommendations for patients with chronic kidney disease.
Dietary restrictions include; 1
Restricting fluid intake
Limit protein intake
Restricting dietary phosphorous, potassium, sodium and other electrolytes
Fluids1
Initially fluid restriction may not be a concern, however as progression to dialysis occurs, it becomes more pertinent to restrict fluid intake. Patients on dialysis will be instructed on how much fluid to restrict following each session. Depending on fluid status, patients will require more or less fluid removal at dialysis sessions. Edema may result in shortness of breath in patients who do not restrict their fluids, ultimately resulting in hospitalization.1
It is important to consider foods that contain a lot of water, such as soups, popsicles, ice cream, grapes, melons, lettuce, tomatoes, and celery.1 These foods may need to be restricted to ensure excess water intake is avoided. It is also advisable to use small cups or glasses, avoid salty foods and stay cool on hot days.
Protein
Protein is essential for the body in order to build muscle and repair tissues.1 Diets that are low in protein are usually essential prior to initiating dialysis. Protein is broken down to urea (a waste product) that can build up and cause uremia.1
A protein controlled diet (0.8-1.0 g/kg/d) is recommended for individuals with chronic kidney disease.2 Protein is found in animal-based products (eggs, fish, meat, chicken and milk) and plant-based products (nuts, peanut butter, beans and chick peas). 2 During dialysis protein is lost and additional protein supplementation may be required to conserve protein energy.
Potassium
As kidney function declines, potassium accumulates because the kidneys are unable to excrete excess potassium. Maintaining potassium is pertinent to preventing irregular heart rhythms. Potassium is found in many foods, which need to be restricted in individuals with CKD. These foods include: 1
Potassium levels will be regularly monitored during monthly appointments.
Sodium
Sodium restriction is important to limit fluid intake, limit fluid retention and control blood pressure. It is recommended that sodium intake is less then 2 g of sodium daily.2 Patients should be instructed to look for products containing less then 100 mg of salt in them. They should also avoid salt substitutes as many contain potassium. 2
Medications
It is important to continue to take medications that control blood pressure, blood sugar and other co-morbidities. See Prevention on the CKD page for appropriate utilization of medications to control blood pressure and blood sugar. It is also important to ensure medications are adjusted according to kidney function. Once dialysis is initiated, it is imperative to ensure medications are timed according to dialysis, as some medications are removed in the dialysate.
Phosphate Binders are utilized to lower the levels of phosphorous in the blood. Observational studies have linked an increase in phosphate (>1.78 mmol/L) to an increased rate of mortality.3 Phosphate binders work by forming a complex with phosphate in the gut before it is absorbed into the blood. The complex is then excreted via the faeces. 3
Treatment for anemia include intravenous iron, erythropoietin stimulating agents and blood transfusions. Varying agents are utilized depending upon institution and physician preference.4
Vitamin D and calcimimetics are utilized to decrease parathyroid hormone (PTH) and decrease bone metabolism. Bone metabolism results in increased fracture risk, cardiovascular disease and ultimately mortality. 4
Replavite - a vitamin B and C complex is utilized to replace various water-soluble vitamins that are lacking in patients with chronic kidney disease on dialysis. 3
Always tell your patents to talk to their pharmacist or doctor before taking any over-the-counter medicine, vitamin, or herbal supplements.
Dialysis
Eventually dialysis or transplantation, combined with diet and medications, will be required to continue living. If no treatment option is selected, short-term and long-term complications will develop, ultimately resulting in death.4
Transplant
The best way of treating CKD is transplant due to the advances in kidney transplant methods and improvement in success with transplant.
There are two types of kidney transplants;5
1. Transplant from live donor
2. Transplant from a deceased donor
After a patient is determined to be suitable for a transplant they are placed on a waiting list. The length of time on this list is unpredictable and may vary depending on region.
Due to increasing technology and transplant techniques, transplants have a very high success rates. Transplants from live donors have a 90 to 95% success rate and from deceased donors have an 85 to 90 % success rate.5
Chronic kidney disease requires an interprofessional team to collaboratively work in the best interest of the patient. Collaboration is key to ensure all aspects of health (diet, medications, medical conditions, psychological status) of a patient with CKD are considered and optimized to ensure maximal health benefit.
Initially diet and medications are utilized to perserve kidney function and slow the progression to end-stage renal disease.
Diet
It is important to make changes in diet to compensate for the kidneys which are not properly functioning and cannot excrete certain food breakdown products. Certain dietary restrictions will prevent waste build-up and maintain balance. It is also important to ensure patients with CKD intake enough calories to prevent muscle breakdown. A dietician will review the important diet recommendations for patients with chronic kidney disease.
Dietary restrictions include; 1
Restricting fluid intake
Limit protein intake
Restricting dietary phosphorous, potassium, sodium and other electrolytes
Fluids1
Initially fluid restriction may not be a concern, however as progression to dialysis occurs, it becomes more pertinent to restrict fluid intake. Patients on dialysis will be instructed on how much fluid to restrict following each session. Depending on fluid status, patients will require more or less fluid removal at dialysis sessions. Edema may result in shortness of breath in patients who do not restrict their fluids, ultimately resulting in hospitalization.1
It is important to consider foods that contain a lot of water, such as soups, popsicles, ice cream, grapes, melons, lettuce, tomatoes, and celery.1 These foods may need to be restricted to ensure excess water intake is avoided. It is also advisable to use small cups or glasses, avoid salty foods and stay cool on hot days.
Protein
Protein is essential for the body in order to build muscle and repair tissues.1 Diets that are low in protein are usually essential prior to initiating dialysis. Protein is broken down to urea (a waste product) that can build up and cause uremia.1
A protein controlled diet (0.8-1.0 g/kg/d) is recommended for individuals with chronic kidney disease.2 Protein is found in animal-based products (eggs, fish, meat, chicken and milk) and plant-based products (nuts, peanut butter, beans and chick peas). 2 During dialysis protein is lost and additional protein supplementation may be required to conserve protein energy.
Potassium
As kidney function declines, potassium accumulates because the kidneys are unable to excrete excess potassium. Maintaining potassium is pertinent to preventing irregular heart rhythms. Potassium is found in many foods, which need to be restricted in individuals with CKD. These foods include: 1
- potato, sweet potato
- tomato, avocado, beans (i.e baked beans, soy beans) and lentils
- banana, custard apple, stone fruits such as nectarines
- dried fruit, vegetable juice, kiwi fruit and olives
- soups
- liqueurs, red wine, cider, stout, nuts and seeds
- spinach, mushrooms
- dried peas, beans, baked beans
- chocolates, cocoa, liquorice
- high fibre breakfast cereals, unprocessed bran
Potassium levels will be regularly monitored during monthly appointments.
Sodium
Sodium restriction is important to limit fluid intake, limit fluid retention and control blood pressure. It is recommended that sodium intake is less then 2 g of sodium daily.2 Patients should be instructed to look for products containing less then 100 mg of salt in them. They should also avoid salt substitutes as many contain potassium. 2
Medications
It is important to continue to take medications that control blood pressure, blood sugar and other co-morbidities. See Prevention on the CKD page for appropriate utilization of medications to control blood pressure and blood sugar. It is also important to ensure medications are adjusted according to kidney function. Once dialysis is initiated, it is imperative to ensure medications are timed according to dialysis, as some medications are removed in the dialysate.
Phosphate Binders are utilized to lower the levels of phosphorous in the blood. Observational studies have linked an increase in phosphate (>1.78 mmol/L) to an increased rate of mortality.3 Phosphate binders work by forming a complex with phosphate in the gut before it is absorbed into the blood. The complex is then excreted via the faeces. 3
Treatment for anemia include intravenous iron, erythropoietin stimulating agents and blood transfusions. Varying agents are utilized depending upon institution and physician preference.4
Vitamin D and calcimimetics are utilized to decrease parathyroid hormone (PTH) and decrease bone metabolism. Bone metabolism results in increased fracture risk, cardiovascular disease and ultimately mortality. 4
Replavite - a vitamin B and C complex is utilized to replace various water-soluble vitamins that are lacking in patients with chronic kidney disease on dialysis. 3
Always tell your patents to talk to their pharmacist or doctor before taking any over-the-counter medicine, vitamin, or herbal supplements.
Dialysis
Eventually dialysis or transplantation, combined with diet and medications, will be required to continue living. If no treatment option is selected, short-term and long-term complications will develop, ultimately resulting in death.4
Transplant
The best way of treating CKD is transplant due to the advances in kidney transplant methods and improvement in success with transplant.
There are two types of kidney transplants;5
1. Transplant from live donor
2. Transplant from a deceased donor
After a patient is determined to be suitable for a transplant they are placed on a waiting list. The length of time on this list is unpredictable and may vary depending on region.
Due to increasing technology and transplant techniques, transplants have a very high success rates. Transplants from live donors have a 90 to 95% success rate and from deceased donors have an 85 to 90 % success rate.5
References
1. Medline Plus. Diet – Chronic Kidney Disease. 2012. Web. 11 Jan 2013. <http://www.nlm.nih.gov/medlineplus/ency/article/002442.htm> 2. Levin A, Hemmelgarn B, Culleton B et al. (2008). Guidelines for the management of chronic kidney disease. CMAJ, 179, 1154-1162.
3. Tonelli M., Pannu N., & Manns B. (2010). Oral Phosphate Binders in Patients with Kidney Failure. NEJM, 362, 1312-24.
4. 1. Herbert L. Chronic Kidney Disease. September 2011. Web. 04 Jan 2013. <http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001503/ >
5. The Kidney Foundation of Canada. Transplantation. 2012. Web. 06 Jan 2013
< http://www.kidney.ca/page.aspx?pid=340 >
1. Medline Plus. Diet – Chronic Kidney Disease. 2012. Web. 11 Jan 2013. <http://www.nlm.nih.gov/medlineplus/ency/article/002442.htm> 2. Levin A, Hemmelgarn B, Culleton B et al. (2008). Guidelines for the management of chronic kidney disease. CMAJ, 179, 1154-1162.
3. Tonelli M., Pannu N., & Manns B. (2010). Oral Phosphate Binders in Patients with Kidney Failure. NEJM, 362, 1312-24.
4. 1. Herbert L. Chronic Kidney Disease. September 2011. Web. 04 Jan 2013. <http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001503/ >
5. The Kidney Foundation of Canada. Transplantation. 2012. Web. 06 Jan 2013
< http://www.kidney.ca/page.aspx?pid=340 >