Primary prevention
The evidence for the prevention of CKD is lacking as compared with large scale randomized trials for cardiovascular disease. Most trials have focused on modifiable diseases and risk factors that have been associated with CKD, namely diabetes and hypertension. Clinical evidence supports the recommendation for a goal HbA1c <7%, blood pressure target of <140/90 mmHg, tobacco cessation, and ideal body weight with BMI <27 to prevent the development of CKD. Due to the lack of widespread screening guidelines with serum creatinine or urinary albumin, often patients are diagnosed after CKD has developed.[36]de Jong PE, Brenner BM. From secondary to primary prevention of progressive renal disease: the case for screening for albuminuria. Kidney Int. 2004 Dec;66(6):2109-18.
http://www.ncbi.nlm.nih.gov/pubmed/15569300?tool=bestpractice.com
Secondary prevention
Underlying risk factors associated with disease states should be treated, including optimization of glycemic control in diabetes and achievement of the goal blood pressure of <140/90 mmHg with ACE inhibitors or angiotensin-II receptor antagonists. Consideration can be given to a lower blood pressure goal in those with proteinuria of >500 mg per 24 hours.[68]James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014 Feb 5;311(5):507-20.
https://jamanetwork.com/journals/jama/fullarticle/1791497
http://www.ncbi.nlm.nih.gov/pubmed/24352797?tool=bestpractice.com
[137]Xie X, Atkins E, Lv J, et al. Effects of intensive blood pressure lowering on cardiovascular and renal outcomes: updated systematic review and meta-analysis. Lancet. 2016 Jan 30;387(10017):435-43.
http://www.ncbi.nlm.nih.gov/pubmed/26559744?tool=bestpractice.com
[69]Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2018 May 15;71(19):e127-248.
https://www.sciencedirect.com/science/article/pii/S0735109717415191?via%3Dihub
http://www.ncbi.nlm.nih.gov/pubmed/29146535?tool=bestpractice.com
[72]Kidney Disease: Improving Global Outcomes (KDIGO). KDIGO clinical practice guideline for the management of blood pressure in chronic kidney disease. Kidney Int Suppl. 2012 Dec;2(5):337-414.
https://kdigo.org/wp-content/uploads/2016/10/KDIGO-2012-Blood-Pressure-Guideline-English.pdf
Although data are limited in the CKD population as compared with the general population, tobacco cessation, weight loss, salt restriction, and optimal lipid management with statin therapy are indicated. Moderate protein restriction is recommended in late stage (GFR category G4 or G5) disease, as a management strategy to control uremia in order to delay the initiation of dialysis.[110]Hahn D, Hodson EM, Fouque D. Low protein diets for non-diabetic adults with chronic kidney disease. Cochrane Database Syst Rev. 2018 Oct 4;(10):CD001892.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6517211/
http://www.ncbi.nlm.nih.gov/pubmed/30284724?tool=bestpractice.com
Severe protein restriction may result in malnourishment and poorer outcomes. Aspirin use has also been beneficial for cardioprotection in those with CKD, although there is a higher risk for minor bleeding than in the general population.