Chronic kidney disease - Treating chronic kidney disease

Lifestyle changes

The following lifestyle changes are known to help reduce your blood pressure and help control CKD:

• stopping smoking
• eating a healthy, low-fat, balanced diet 
• restricting your salt intake to less than 6g (0.2oz) a day
• not using over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, except when advised to by a medical professional
• moderating your alcohol intake so it is within recommended limits (no more than 3-4 units a day for men and 2-3 units a day for women) 
• losing weight if you are overweight or obese 
• doing regular exercise for at least 30 minutes a day, five times a week

Read more about preventing high blood pressure through lifestyle changes.

Medications for high blood pressure

One of the main ways to reduce the progression of kidney damage is to manage high blood pressure. Good control of blood pressure is vital to protect the kidneys.

People with CKD should aim to get their blood pressure down to below 140/90mmHg but if you also have diabetes you should aim to get it down to below 130/80mmHg.

There are many types of blood pressure drugs. Medicines called angiotensin converting enzyme (ACE) inhibitors are used to control high blood pressure in people with CKD.

As well as reducing blood pressure around the body and reducing the strain on blood vessels, ACE inhibitors give additional protection to the kidney.

ACE inhibitors include:

• ramipril 
• enalapril 
• lisinopril 
• perindopril

Side effects of ACE inhibitors include:

• a persistent, dry cough 
• dizziness 
• tiredness or weakness 
• headaches

Most of these side effects should pass within a few days, although some people continue to have a dry cough.

If the side effects of ACE inhibitors are particularly troublesome, you can be given an alternative medication called an angiotensin-II receptor blocker (ARB). This group of medicines includes:

• candesartan
• eprosartan
• irbesartan
• azilsartan
• olmesartan
• temisartan
• valsartan
• losartan

The side effects of ARBs are uncommon, but can include dizziness.

Both ACE inhibitors and ARBs can cause a reduction in kidney function in some people and increased levels of potassium in the blood, so blood tests will need to be performed after you start treatment and whenever the dose changes. If you are on an ACE inhibitor or ARB and you develop a fever/infection or need medicines for other conditions, it's important to ask your doctor if the ACE inhibitor or ARB needs to be temporarily stopped.

Medication to reduce cholesterol

Studies have shown that people with CKD have a higher risk of cardiovascular disease, including heart attacks and strokes. This is because some of the risk factors for CKD are the same as those for heart attacks and strokes, including high blood pressure and high levels of cholesterol in the blood (atherosclerosis).

Statins are a type of medication used to lower cholesterol levels. Cholesterol causes narrowing of the arteries that can lead to a blockage of the blood supply to the heart (causing a heart attack) or the brain (causing a stroke). Statins work by blocking the effects of an enzyme in your liver (called HMG-CoA reductase), which is used to make cholesterol.

Statins sometimes have mild side effects, including:

• constipation
• diarrhoea 
• headaches 
• abdominal pain

Occasionally, statins can cause muscle pain, weakness and tenderness. If you experience any of these symptoms, contact your GP. You may need to have a blood test or change your treatment.

If you have kidney disease, you may be asked to reduce your daily fluid and salt intake. You may develop a build-up of fluid as your kidneys will not be able to get rid of fluid as well as they did before.

If you are asked to reduce the amount of fluid you drink, you must also take into account fluid in foods, such as soup and yoghurt. Your GP or dietitian can advise you about this.

The excess fluid that occurs as a result of kidney disease often builds up in your ankles or around your lungs. You may also be given diuretics (water tablets), such as furosemide, which will help get rid of the excess fluid from your body.

If you do not have any fluid retention and you have not been told to reduce your fluid intake, there is no need to do so. In fact, it could be harmful in some circumstances.

Anaemia

Many people with stage three, four and five CKD develop anaemia. Anaemia is a condition in which you do not have enough red blood cells. Symptoms of anaemia include:

• tiredness 
• lethargy 
• shortness of breath (dyspnoea) 
• palpitations (awareness of heartbeat) 

Anaemia can occur because of many other conditions and your doctor will investigate to rule out other possible causes.

Most people with kidney disease will be given iron supplements because iron is needed for the production of red blood cells. To boost iron levels, iron may be given as tablets, such as daily ferrous sulphate tablets, or as occasional intravenous infusions.

If this is not enough to treat anaemia, you may be started on injections of erythropoietin, a hormone which helps your body produce more red blood cells. These injections are often administered into a vein (intravenously) or under the skin (subcutaneously). Examples of these injections include epoetin alfa, beta and zeta, darbepoetin and methoxy polyethylene glycol-epoetin beta.

Want to know more? 

• NICE: Treating anaemia in people with chronic kidney disease

Correction of phosphate balance

If you have stage four or five kidney disease, you can get a build-up of phosphate in your body because your kidneys cannot get rid of it. Phosphate is a mineral that, with calcium, makes up most of your bones. Phosphate is obtained through diet, mainly dairy foods. The kidneys usually filter out excess phosphate. If phosphate levels rise too much, it can upset the normal calcium balance of the body. This can lead to thinning of the bones and furring of the arteries.

You may be asked to limit the amount of phosphate in your diet. Foods high in phosphate include red meat, dairy produce, eggs and fish. Your GP or dietitian should be able to advise you about how much phosphate you can eat. However, there is no advantage in reducing your intake of these foods unless you have a raised phosphate level. Always ask a healthcare professional before changing your diet.

If reducing the amount of phosphate in your diet does not lower your phosphate level enough, you may be given medicines called phosphate binders. These medicines bind to the phosphate in the food inside your stomach and stop it from being absorbed into your body.

To work properly, phosphate binders must be taken just before meals. The most commonly used phosphate binder is calcium carbonate, but there are also alternatives that may be more suitable for you.

The side effects of phosphate binders are uncommon but include:

• nausea 
• stomach ache 
• constipation 
• diarrhoea 
• flatulence (wind) 
• skin rash 
• itchy skin

Vitamin D supplements

People with kidney disease can have low levels of vitamin D, necessary for healthy bones. This is because the kidneys need to activate the vitamin D from food and the sun before it can be used by the body.

Treatment for kidney failure – transplant or dialysis

Many people with kidney failure can continue with treatment using medicines and will have good-functioning kidneys for the rest of their lives.

In a few people, kidney disease will progress to the stage where the kidneys stop working and it becomes life threatening. This is called kidney failure or established renal failure (ERF).

This rarely happens suddenly, and there will be time to plan the next stage of your condition. The decision whether to have dialysis, a kidney transplant or supportive treatment should be discussed with your healthcare team.

Read more about dialysis and kidney transplants.

Supportive treatment

If you decide not to have dialysis or a transplant for kidney failure, or they are not suitable for you, you will be offered supportive treatment.

This is also called palliative care.

The aim is to treat and control the symptoms of kidney failure without using dialysis or transplantation. Supportive treatment includes medical, psychological and practical care for both the person with kidney failure and their family, including discussion about how you feel and planning for the end of life.

Many people choose supportive treatment because they:

• are unlikely to benefit or have quality of life with treatment
• do not want to go through the inconvenience of treatment with dialysis
• are advised against dialysis because they have other serious illnesses that will shorten their life, and the negative aspects of treatment outweigh any likely benefits 
• have been on dialysis but have decided to stop this treatment 
• are being treated with dialysis, but have another serious physical illness, especially severe heart disease or stroke, that will shorten their life

If you choose to have supportive treatment, your kidney unit will still look after you.

Doctors and nurses will make sure you receive:

• medicines to protect your remaining kidney function for as long as possible 
• medicines to treat other symptoms of kidney failure, such as feeling out of breath, anaemia, loss of appetite or itchy skin 
• help to plan your home and money affairs 
• bereavement support for your family after your death

Want to know more?

• Kidney Research UK: Information on choosing not to start dialysis
• National Kidney Federation: End of life care for people with advanced kidney disease
• Bereavement support from CRUSE

What is good kidney disease care?

According to a national review, kidney disease services should:

• identify people at risk of kidney disease, especially people with high blood pressure or diabetes, and treat them as early as possible to maintain their kidney function 
• give people access to investigative treatment and follow them up to reduce the risk of the disease getting worse 
• give people good-quality information about managing their condition 
• provide information about the development of the disease and treatment options 
• provide access to a specialist renal (kidney) team 
• give people access to transplant or dialysis services if required
• provide supportive care

Your treatment for kidney disease will need to be reviewed regularly.

It may be helpful for you to make a care plan because this can help you manage your day-to-day health. Your kidney disease specialist nurse may be able to help with this.

What is a care plan?