The recently published Kidney Disease 2024: Improving Global Outcomes (KDIGO) Clinical Practice Guidelines for the Assessment and Management of Chronic Kidney Disease (CKD) calls for early diagnosis and intervention, particularly to reduce mortality and improve kidney disease. There is a new focus on referral to specialists to slow the progression of the disease. Both CKD and cardiovascular disease. Even if treatment with kidney replacement therapy is not an option, lifestyle changes can slow the progression of the disease.
KDIGO recommends that patients be referred to nephrology services if the estimated glomerular filtration rate (eGFR) is less than 30 mL/min/1.73 m.2. Delayed referral to nephrology has been shown to increase progression to end-stage renal disease and the need for renal replacement therapy.
In my experience, delayed referrals often leave patients feeling overwhelmed and poorly educated about their condition and treatment options, leading to decreased compliance with medications, diet, dialysis, and other interventions.
The most cost-effective and perhaps most efficient of these treatment options are lifestyle changes such as exercise, increased intake of plant-based foods, and regular review of over-the-counter supplements and herbs.
Exercise for prevention
KDIGO recommends at least 150 minutes of vigorous or moderate exercise each week for appropriate patients. For patients with obesity, hypertension, and diabetes, exercise can prevent the progression of her CKD. The guidelines note that individual activity recommendations should be based on each patient's abilities, comorbidities, frailty, fall risk, and resources.
Guidelines published in 2012 recommend that clinicians advise patients to maintain a body mass index (BMI) between 20 and 25. The current guidelines do not make such a recommendation and only refer to weight loss in obese patients (BMI > 30).
Clinicians may find this latest information refreshing, as studies have shown that patients aged 65 years and older with a BMI in the overweight range have lower mortality rates than those with a BMI less than 25. This gives those of us working with patients the support they need. Rather than wasting valuable time educating people about weight loss who may not benefit from weight loss, we should address the patients' actual problems.
More plants, less UPF
The new guidelines recommend limiting intake of ultra-processed foods (UPF), which is consistent with previous recommendations. Highly processed foods are often high in sodium, sugar, and bioavailable potassium, which can promote hyperuricemia. Recommendations to limit intake of processed foods are expected to be beneficial for CKD patients who have many comorbidities such as diabetes, hypertension, heart failure, liver disease, and gout.
The most notable update is the emphasis on eating plant-based foods. This has long been a topic of debate in the nephrology world, as nuts, legumes, fruits, and vegetables can be rich in potassium and phosphorus.
Although it is recommended that patients with hyperkalemia or at risk for hyperkalemia limit their intake of potassium-rich foods, potassium intake from processed foods is of greatest concern. This reinforces other recommendations to limit UPF without compromising the importance of adequate intake of whole foods.
Studies have shown a correlation between a plant-based diet rich in potassium-rich fruits, vegetables, and legumes and slowing the progression of CKD, possibly through resolution of metabolic acidosis. I work with many CKD patients who have started cutting out legumes, fruits, and vegetables, including those that are not rich in potassium, because they were misled by friends, family, the internet, and even other healthcare professionals. I've been working. For this reason, I find this recommendation particularly encouraging and look forward to the positive effects of updated guidelines in the coming years.
Review supplements and herbal medicine
Recommendations that drugs, supplements, and herbal medicines should be reviewed for nephrotoxicity have existed for some time. However, recent guidelines encourage the inclusion of a multidisciplinary team, namely the pharmacist, in the management of complex medication regimens.
Pharmacists tend to be underutilized in the nephrology world. They are the experts we turn to when we have questions or concerns about prescriptions, but they are also trained in the use of supplements and herbal remedies. I've seen patients withhold things like turmeric, fish oil, colloidal silver, and hibiscus tea from their medication lists because they don't consider supplements to be medicines worthy of a clinician's attention. Also, while some supplements such as fish oil may be beneficial for kidney patients, the same cannot be said for other supplements, especially when it comes to drug interactions and polypharmacy.
Healthcare professionals, including non-prescribers such as RDs and RNs, can help interdisciplinary teams by asking about additional supplements patients are taking and providing appropriate education about supplements and their potential risks. must be consistently supported. As a dialysis dietitian, I often receive patient questions about various herbs and supplements. These questions gave me a great opportunity to discuss the importance of transparency with patients and encourage them to bring their questions about supplements to the team.
As I reviewed the updated guidelines, I found it most reassuring that they repeatedly recommended the use of a multidisciplinary team of specialized nurses, pharmacists, therapists, and nutritionists. We can't be everything to our patients, but with a team approach, we don't have to. This approach to kidney care can educate and empower people living with CKD to do everything they can to prevent disease progression while considering patient choice and quality of life.