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Severe Kidney Disease Needs Complex Management

Case vignette describes aggressive strategies aimed at slowing disease progression

WEDNESDAY, Jan. 6 (HealthDay News) -- Aggressive management is required for patients with stage IV chronic kidney disease, according to an article in the Jan. 7 issue of the New England Journal of Medicine.

Hanna Abboud, M.D., of the University of Texas Health Science Center in San Antonio, and a colleague presented a vignette in which a 54-year-old woman with advanced diabetic kidney disease and proteinuria, and a strong likelihood of progressing to end-stage renal disease, presents for treatment.

The authors recommended therapy aimed at slowing disease progression, reducing the risk of cardiovascular disease, treating coexisting conditions, and preparing the patient for renal-replacement therapy. Recommended medications included an angiotensin-receptor blocker or ACE inhibitor to slow the decline in the glomerular filtration rate, a loop diuretic instead of a thiazide diuretic, and the addition of a beta-blocker, calcium-channel blocker, or both, if optimal blood pressure is not achieved.

"Whereas the current guidelines of the Kidney Disease Outcomes Quality Initiative recommend a target hemoglobin concentration of 11 to 12 g per deciliter, the appropriate hemoglobin target in patients with stage IV chronic kidney disease remains uncertain and requires further study. Iron deficiency should routinely be assessed and treated," the authors write. "Patients should be informed about methods of renal-replacement therapy, and efforts should be made to preserve the venous circulation in the upper extremities in order to maintain vascular access in those patients who opt for hemodialysis."

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