Chronic kidney disease: Australian facts

The general goal of treatment for chronic kidney disease (CKD) is to reduce the progression of the disease and reduce cardiovascular risk. Typically, this involves the use of medicines that treat comorbidities and risk factors, and can offer protection against further kidney damage in the early stages of the disease. Managing existing conditions like diabetes, high blood pressure and cardiovascular disease before kidney disease develops and in the early stages of CKD is critical in protecting the kidneys in the long-term.

The cause of CKD is important in determining the most appropriate treatment and management strategies, as these usually depend on the underlying condition.

Managing diabetes

Methods of controlling blood sugar include medication and engaging in healthy lifestyle practices, including physical activity and eating a healthy diet.

Medications often prescribed for type 2 diabetes are:

• insulin
• metformin
• sodium-glucose transporter 2 (SGLT2) inhibitors
• DPP-4 inhibitors
• glucagon-like-peptide-1 receptor agonists/analogues.

Sodium-glucose transporter 2 inhibitors

SGLT2 inhibitors are a class of glucose-lowering drugs used in managing type 2 diabetes. They work by reducing the amount of glucose that is reabsorbed in the kidneys, promoting its excretion in the urine.

Multiple clinical trials have shown SGLT2 inhibitors to be effective in delaying the progression of CKD in people with and without type 2 diabetes (Heerspink et al. 2020, Li et al. 2021, Neal et al. 2017, Perkovic et al. 2019).

In September 2021, the Therapeutic Goods Administration approved dapagliflozin for treatment of CKD to reduce the risk of progressive decline in kidney function in adults with proteinuric CKD (stage 2, 3 or 4 and urine ACR≥ 30 mg/g) (TGA 2021). In September 2022, treatment of CKD was added to the Pharmaceutical Benefits Scheme listing for dapagliflozin (PBS 2022).

For more information, see Diabetes medicines.

Managing cardiovascular disease

High blood pressure

Medications that may be prescribed to control high blood pressure, include:

• ACE inhibitors
• ARBs
• beta blockers
• diuretics.

As with all medication in people with CKD, these need to be carefully monitored and adjusted or ceased depending on a person’s individual circumstances and their level of kidney function.

High cholesterol

Statins are a first line treatment for managing high cholesterol; however, some research has indicated that the use of statins in people receiving dialysis shows limited benefits and can potentially be harmful (Kennard and Singer 2017). For people with CKD not on dialysis, combining statin therapy with ezetimibe has been shown to reduce the risk of adverse kidney events compared with statin use alone (Bae et al. 2020, CARI Living Guideline Lipid Work Group 2021).

For more information, see Medicines for cardiovascular disease.

Managing medications in chronic kidney disease

In stages 3–5 CKD, medicine use must be carefully managed. This is because medicines that are excreted through the kidneys have the potential to build up in the body and be toxic to the kidneys or other organs (Hartmann et al. 2010). To avoid this, clinical assessment and management of medication are important components of treating and managing later stages of CKD.

Management should be tailored to each individual and may involve stopping or lowering the dosage of certain medications or, when available, using alternatives that are not eliminated from the body through the kidneys (Faull and Lee 2007, Hartman et al. 2010, KHA 2020).

Because CKD is typically caused by another health condition, comorbidity and multimorbidity are common. This means that many people with CKD are prescribed complex medication regimens, which need to be monitored and adjusted to achieve the best outcomes.

The use of multiple medications to manage underlying chronic conditions increases the chances of drug interactions, as well as adverse outcomes such as hospitalisation, falls, and mortality (Manski-Nankervis et al. 2021). In Australia, medication reviews are subsidised under Medicare and may be beneficial for people with CKD to simplify their medication regimen.