Achieving better quality of life and survival for patients with chronic kidney disease

September 29, 2021

In a recent article in The Lancet, UCI Health nephrologist Kamyar Kalantar-Zadeh, MD, MPH, PhD, and colleagues, describe the conservative management of chronic kidney disease through kidney preserving care as a viable method to slow chronic kidney disease progression and prolong dialysis­free time while striving to achieve the greatest quality of life and survival.

The incidence of chronic kidney disease (CKD) affects 10%-12% of the adult population worldwide and is growing, says Kalantar, chief, Division of Nephrology, Hypertension and Kidney Transplantation, UCI School of Medicine. It causes 1.2 million deaths annually and consumes enormous health-care resources.

“By 2040, chronic kidney disease is estimated to become the fifth leading cause of death globally, representing one of the largest projected increases of any major cause of death,” Kalantar says.

A primary goal is prevention of kidney failure and cardiovascular disease, for which there is an exceptionally high burden in CKD patients – many of whom die of cardiovascular events before progressing to more advanced stages of the disease, including renal failure. Healthy lifestyle behaviors, blood pressure lowering, maintaining glucose control (in people with diabetes), and renin and angiotensin aldosterone system (RAAS) blockers have been the cornerstone of therapy for patients with CKD since the late 1990s. Several new drugs and therapies have recently been shown to slow the progression of CKD to kidney failure including the Sodium-glucose Cotransporter-2 (SGLT2) Inhibitors and selective aldosterone receptor antagonists but more studies are needed to examine their safety and efficacy across different stages of CKD. Kalantar and others have increasingly studied diet modifications as a key component of successful CKD management.

The authors reviewed biomedical literature to identify all studies in which the effects of diet and lifestyle modifications and pharmacotherapeutic interventions were examined for conservative or preservative management of chronic kidney disease.

Kalantar has long been a proponent of conservative management of CKD to prevent or delay progression to renal failure, dialysis and kidney transplantation. In a 2020 New England Journal of Medicine editorial “Ensuring choice for people with kidney failure — dialysis, supportive care, and hope,” Kalantar and colleagues highlighted the need for clinicians to fully present opportunities and ethical choices to patients who face end-stage renal disease.

In another New England Journal of Medicine article, “Nutritional Management of Chronic Kidney Disease,” Kalantar addressed the long-term negative impact of high protein diets and highlighted the need for better nutritional management in patients with CKD.

In the recent Lancet article, Kalantar says there has been growing recognition that conservative management, including with kidney-preserving approaches and without dialysis, is a viable patient-centered treatment option for many people with chronic kidney disease.

However, Kalantar says there is no clear consensus around whether diet and lifestyle modifications, including a low-protein diet with more than 50% of protein being sourced from plants, also known as plant-dominant or PLADO diet, can mitigate proteinuria and preserve kidney function for longer in people with mild to moderate chronic kidney disease, or can attenuate uremia by reducing the burden of nitrogenous end-products, through favorable alterations in the gut microbiome, and by mitigating metabolic acidosis.

“To ensure optimal kidney preserving care and for patients to reach greater longevity and superior health-related quality of life, additional studies on pre-existing interventions and development of innovative strategies are warranted,” Kalantar says.

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