If you have chronic kidney disease (CKD), diabetes, or high blood pressure—or if you take certain blood pressure medicines that affect your kidneys—you should take steps to protect your kidneys from harm.
ACE inhibitors and ARBs are two types of blood pressure medicine that may slow the loss of kidney function and delay kidney failure. You can tell if you’re taking one of these medicines by its generic name. ACE inhibitors end in –pril and ARBs have generic names that end in –sartan; for example, lisinopril and losartan.
The next time you pick up a prescription or buy an OTC medicine or supplement, ask your pharmacist how the product may affect your kidneys or react with other medicines you take.
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Fill your prescriptions at only one pharmacy or pharmacy chain so your pharmacist can monitor your medicines and supplements, and check for harmful interactions between your medicines.
Keep an up-to-date list of your medicines and supplements in your wallet. Take your list with you, or bring all your medicine bottles, to all health care visits.
If you take OTC or prescription medicines for headaches, pain, fever, or colds, you may be taking a nonsteroidal anti-inflammatory drug (NSAID). NSAIDs include popular pain relievers and cold medicines that can damage your kidneys if you take them for a long time, or lead to acute kidney injury if you take them when you are dehydrated or your blood pressure is low.
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Ibuprofen and naproxen are NSAIDs. NSAIDs are sold under many different brand names, so ask your pharmacist or health care provider if the medicines you take are safe to use.
Almost everyone gets sick once in a while. Your doctor or pharmacist can help you plan ahead to keep your kidneys safe until you get well. Prepare in advance so you know what to do if you have pain or a fever, diarrhea, nausea, or vomiting, which can lead to dehydration.
In normal, everyday circumstances, taking your blood pressure medicines as prescribed helps protect your kidneys. However, certain situations, such as when you’re dehydrated from the flu or diarrhea, can lower the blood flow to your kidneys and cause harm.
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When you get sick from something like the flu or diarrhea, or have trouble drinking enough fluids, the blood pressure in your body may decrease. As a result, the pressure in your kidneys can be low, too.
In most cases, healthy kidneys can protect themselves. However, if you keep taking your blood pressure medicines when you’re dehydrated or have low blood pressure, your kidneys might have a hard time protecting themselves. The pressure within your kidneys might drop so low that your kidneys won’t filter normally.
If you’re dehydrated, NSAIDs can also keep your kidneys from protecting themselves. As a result, taking NSAIDs when you’re sick and dehydrated can cause kidney injury.
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Read about what else you can do to keep your kidneys healthy. If you already have CKD, the steps you take to protect your kidneys also may help prevent heart disease—and improve your health overall.
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The would like to thank Jeffrey Fink, MD, MS, Chief, Division of General Internal Medicine, University of Maryland School of MedicineThis article discusses guidelines and practical recommendations on when and how to prescribe medicines shown to slow progression of chronic kidney disease and reduce cardiovascular risk.
Australian and international guidance is clear on medicines for chronic kidney disease (CKD) that slow CKD progression and reduce cardiovascular (CV) risk.
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This article provides a practical guide on when and how to prescribe the above medicines for people with CKD. It includes an algorithm (see Figure 2) and follows the case study of a patient named Ken.
The management for each person with CKD is guided by where that person’s estimated GFR (eGFR) and ACR results place them on a colour-coded staging table.
Risk level colour codes: green = low risk, yellow = moderate risk, orange = high risk and red = very high risk.
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Source: KHA-CARI Guideline: Early chronic kidney disease: Detection, prevention and management. Johnson DW, Atai E, Chan M, et al. Nephrology 2013;18:340–50. Wiley Online Library.
The risk levels in the colour-coded CKD staging table correspond to colour-coded clinical action plans presented in the Kidney Health Australia 2020 CKD Management in Primary Care 4th edition handbook.
Each clinical action plan includes a set of clinical and laboratory assessments and measures, management goals, and non-pharmacological management and pharmacological management recommendations, including medicines to slow CKD progression and reduce CV risk.
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An algorithm based on the Australian and international guidance presents the recommended medicines that slow CKD progression and reduce CV risk for people with CKD. See Figure 2 below.
Before going into more detail about the recommended medicines and reviews for Ken to slow CKD progression and reduce CV risk, it can be helpful to address some guiding principles and issues.
CKD rarely occurs in isolation. Of the estimated one in 10 adults with probable CKD in Australia, 35% have CVD and CKD, 6% have type 2 diabetes and CKD, and 11% have all three.
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CKD shares many treatment goals and management strategies with CVD and type 2 diabetes. Taking a ‘whole of person’ approach and managing these chronic conditions in conjunction with one another can lead to improved patient outcomes.
Dr Tim Senior, GP at Tharawal Aboriginal Corporation, clinical senior lecturer at the University of Western Sydney Medical School and CKD expert in general practice
We as GPs are already doing much of what is needed for CKD in our management of these other conditions. You don’t need to do much more to manage CKD.”
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“Prescribing medicines that slow CKD progression and reduce cardiovascular risk for people with newly diagnosed CKD can be done over several consultations. In most cases there is ample time to optimise a patient’s management.
“This enables me to start with the medicines I’m confident prescribing. For many GPs this will be an ACE inhibitor or an ARB. For medicines I’m less familiar with, I develop a list of priorities about doses that need to be changed or medicines started.
“I know I have time to upskill or refresh my knowledge when required before the next appointment by reading the guidance or contacting my local hospital renal service or a private nephrologist. So when the patient comes back, I can be confident with prescribing them.”
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Graeme Turner, nurse practitioner in the Northern NSW Local Health District and co-author of the 2013 KHA-CARI Guideline: Early chronic kidney disease: Detection, prevention and management
“The main task with person-centred care is to spark interest and help people with CKD be motivated to get involved in their care from the start.
“This involves finding ways to give the person a feeling they have some control over their health, rather than the health professional trying to control their health.
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“CKD has its challenges, particularly because it is usually asymptomatic. I find using the colour-coded staging table can be helpful. I explain that taking their medicines and making lifestyle changes can reduce their ACR number, which means they’re slowing the progression of disease. You can use reducing their blood pressure number as a motivator in the same way.”
“My approach is to first pick the low-hanging fruit. I look at what the patient is already taking and prioritise a dose that needs up-titrating. Then I prioritise treating the underlying cause and any comorbidities.
“Patients often need to take multiple medicines, so you need to have their agreement to come back over a number of appointments to monitor them and see what works. You don’t have to do everything at once, your focus is on the long term and building your relationship with the patient.”
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Professor Ivor Katz, nephrologist at St George Hospital in Sydney and member of the Kidney Health Australia Primary Care Educational Advisory committee.
“Compelling indications guide my decisions about which medicines to prescribe. The most compelling are usually targeting the albuminuria level, because it is just such a significant factor for cardiovascular risk, but I still target… hypertension and diabetes and comorbidities like dyslipidaemia and obesity with support from GPs, and for me I will of course also focus on the underlying cause of the CKD if it's not hypertension or diabetes.
“For people with high albuminuria levels, my priority is to up-titrate the ACE inhibitor or ARB to maximum tolerated dose, then
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