Slowing Progression of Chronic Kidney Disease

Early identification of chronic kidney disease (CKD) provides an opportunity to implement therapies to improve kidney function and slow progression. This chapter will first review the epidemiology of progression to define the normal and CKD-related rate of decline in kidney function and discuss the competing risks between death and development of end-stage renal disease. Common pathophysiologic mechanisms underlie the progression of most kidney diseases, including glomerular capillary hypertension, renal fibrosis induced by renal inflammation, podocyte loss, proteinuria, and activation of systems such as the renin-angiotensin-aldosterone system and intrarenal activation of developmental and injury pathways. These pathophysiologic factors present potential targets for therapy. The importance of controlling blood pressure will be discussed along with the target blood pressure in CKD patients. Therapy directed at inhibiting the renin-angiotensin-aldosterone system remains the mainstay of treatment with single agent inhibition of this system being as good as dual blockade with fewer adverse effects. Other therapies include glycemic control, correction of metabolic acidosis, and dietary protein restriction. Emerging therapies targeting endothelin, uric acid, kidney fibrosis, oxidant stress, and kidney augmentation hold promise for the future.