Chronic kidney disease

Strategies for management

Lifestyle and pharmacological strategies to
preserve kidney function and improve outcomes

Intervention strategies
Interventions include non-pharmacological strategies,such as diet
and lifestyle modifications, and pharmacological strategies

Diet and lifestyle For disease progression For cardiovascular risk For other comorbidities Renal replacement

Pharmacological strategies

Timing of implementation
All strategies have a window of optimal effect based on a patient’s stage of kidney function decline

Plant dominant, low-protein diet

Nutrient-focused intervention (low sodium, phosphate, and potassium)
Physical activity
Smoking cessation
Weight reduction*
Renin–angiotensin–aldosterone system blockade Unnecessary weight loss in
SGLT2 inhibitors advanced chronic kidney disease
should be avoided, unless
For individuals with Non-steroidal mineralocorticoid receptor antagonists* absolutely required
diabetic kidney disease
Tolvaptan for polycystic kidney disease
Rituximab* For primary membranous nephropathy
Steroids for IgA nephropathy
Lipid-lowering agents
Blood-pressure lowering agents
Glucose-lowering agents
Sodium and volume management
Potassium binders
Acidosis management
Symptom management
Infection prevention
Dialysis
Transplantation

eGFR 120 60 30 10 0

Increasing Loss of residual

Hyperfiltration Albuminuria Declining GFR
uraemia kidney function

eGFR=estimated glomerular filtration rate (mL/min per 1·73 m2)

Read the full Seminar on chronic kidney disease at thelancet.com/clinic

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Interventions in more detail
Diet and lifestyle strategies Targeting
Intervention Pros Cons CKD CVD Uraemia
Plant dominant, Patient-centered, inexpensive, improves Risk of hyperkalaemia and protein-energy wasting
low-protein diet metabolic parameters, mitigates acidosis; might
slow CKD progression and attenuate uraemia
Nutrient-focussed Traditional familiarity in clinical practice including Excessive dietary potassium restriction can
intervention potassium and phosphorus control deprive patients from intake of healthy diet

Physical activity Numerous clear health benefits including
slower decline in kidney function and
improving cardiovascular profile
Smoking cessation Current and former smoking associated with
greater risk of incident CKD and cardiovascular risk
Excessive physical activity can lead to
rhabdomyolsis, which can cause acute kidney injury
None

Weight reduction Improves cardiometabolic health, might mitigate In dialysis-dependent patients, weight loss can be
glomerular hyperfiltration and slow decline in be associated with poor outcome (obesity paradox)
kidney function, and might improve albuminuria

Pharmacological strategies Targeting

Intervention Pros Cons CKD CVD Uraemia
Renin–angiotensin– Slows CKD progression with clearest benefit in Risk of hyperkalaemia and acute kidney injury
aldosterone system people with substantial albuminuria
blockade
SGLT2 inhibitors Slows and prevents cardiovascular events Higher risk of genital fungal infection and
regardless of diabetes as the cause of CKD nondiabetic ketoacidosis. Cannot be currently
initiated if starting eGFR <25 mL/min/1.73m2
Non-steroidal Reduction in risk of adverse renal and Higher risk of hyperkalaemia; yet to be
mineralocorticoid receptor cardiovascular outcomes in type 2 diabetes evaluated in non-diabetic kidney disease
antagonists
Tolvaptan for polycystic Slows rate of kidney growth and glomerular Higher risk of dehydration and hypernatremia
kidney disease filtration rate decline in autosomal dominant if not responsive to thirst; risk of liver damage
polycystic kidney disease
Rituximab for primary Increases likelihood of long-term remission Little randomised controlled trial data directly
membranous nephropathy comparing with alkylating agents

Steroids for IgA Extensive clinical experience Mixed results in clinical trials, increased risk of
nephropathy adverse events, especially serious infection

Lipid-lowering agents Reduces vascular events in people with No clear benefit for initiating treatment
CKD, well tolerated in people on dialysis therapy

Blood pressure-lowering Reduces cardiovascular and might reduce Greater risk of adverse events, including acute
agents adverse renal outcomes kidney injury, as kidney function declines

Glucose-lowering agents SGLT2-inhibitors and GLP-1 receptor Risk of hypoglycemia and other
agonists reduce adverse cardiovascular treatment related adverse events with
events in type 2 diabetes intensive glucose-lowering therapy
Acidosis management May slow progression of CKD NaHCO3 administration may worsen
pharmacological strategies sodium and fluid retention

Potassium binders Reduces risk of hyperkalaemia associated cardiac
events and might enable use of renin–angiotensin–
aldosterone pathway modulators
Sodium and volume Well established clinical experience
management
No data on patient-level outcomes or
progression of kidney disease
Effect on CKD progression uncertain

Symptom management Important priority for patients with more Unknown to affect risk of CKD
unpleasant symptoms progression or need for dialysis

Infection prevention Many infectious events can cause acute kidney Direct kidney involvement not
injury, faster CKD progression, or both certain, such as in COVID-19

Renal repacement strategies Targeting

Intervention Pros
Dialysis Provides effective therapy for uraemia, fluid
overload, hyperkalaemia, and acidosis;
incremental transition to dialysis is preferred
Kidney transplant The most effective renal replacement therapy if
there is a well functioning allograft
Cons CKD CVD Uraemia
Conventional dialysis therapy can be
associated with unpleasant symptoms, such
as muscle cramps and post-dialysis fatigue
Associated immunosuppression increases
risk of opportunistic infection and cancer

CKD=chronic kidney disease; CVD=cardiovascular disease

Read the full Seminar on chronic kidney disease at thelancet.com/clinic

The best science for better lives