Apart from controlling other risk factors, the goal of therapy is to slow down or halt the progression of<unk> . Control of blood pressure and treatment of the original<unk>  are the broad principles of management. Blood pressure Angiotensin converting enzyme inhibitors (ACEIs) or angiotensin II receptor antagonists (ARBs) are recommended as first-line agents since they have been found to slow the decline of kidney function, relative to a more rapid decline in those not on one of these agents. They have also been found to reduce the risk of major cardiovascular events such as myocardial infarction, stroke, heart failure, and death from cardiovascular<unk>  when compared to placebo in individuals with<unk> . ACEIs may be superior to ARBs for protection against progression to kidney failure and death from any cause in those with<unk> . Aggressive blood pressure lowering decreases people's risk of death. Other measures * Aggressive treatment of high blood lipids is recommended. * A low-protein, low-salt diet may result in slower progression of<unk>  and reduction in proteinuria as well as controlling symptoms of advanced<unk>  to delay dialysis start. A tailored low-protein diet, designed for low acidity, may help prevent damage to kidneys for people with<unk> . Additionally, controlling salt ingestion helps to decrease the incidence of coronary heart<unk> , lowering blood pressure and reducing albuminuria. * Anemia - A target hemoglobin level of 9–12 g/dL is recommended; raising hemoglobin levels to the normal range has not been found to be of benefit. * Guidelines recommend treatment with parenteral iron prior to treatment with erythropoietin. * Replacement of erythropoietin is often necessary in people with advanced<unk> . * It is unclear if androgens improve anemia. * Calcitriol is recommended for vitamin D deficiency and control of metabolic bone<unk> . * Phosphate binders are used to control the serum phosphate levels, which are usually elevated in advanced<unk> . * Phosphodiesterase-5 inhibitors and zinc may improve sexual dysfunction in men. Lifestyle Interventions Obesity may have a negative impact in<unk> , increasing the risk of<unk>  progression to ESKD or kidney failure compared to controls with healthy weight, and when in advanced stages also may hinder people's eligibility to kidney transplantation. Weight management interventions in overweight and obese adults with<unk>  (of various stages) have been studied to assess its safety and efficacy. A recent systematic review collected evidence from 17 studies which evaluated lifestyle (including dietary, physical activity/exercise, or behavioural strategies used in isolation or in combination), pharmacological (used to reduce absorption or suppress appetite) and surgical interventions. The review concluded that lifestyle interventions may provide some health benefits, namely improving body weight, low density lipoprotein (LDL) cholesterol and diastolic blood pressure (DBP), when compared to usual care or controls. Whether these benefits extend to help reducing cardiovascular events, kidney function and risk of death is uncertain. These conclusions were based on very low quality of evidence, so future robust studies are needed. Thus, it is recommended that weight management interventions should be individualised, according to a thorough patients' assessment regarding clinical condition, motivations and preferences. Sleep People with<unk>  suffer from sleep disorders, thus not being able to get quality sleep. There are several strategies that could help, such as relaxation techniques, exercise, acupressure and medication: * Exercise: weak evidence demonstrates that exercise may be helpful with sleep regulation. Nevertheless, exercise possibly decreases fatigue and depression in people with<unk> . * Acupressure: evidence suggests that this technique may have slight effects on latency and sleep duration, as well as on fatigue reduction, although these results are not reliable due to the diversity of conclusions in several articles. Despite all the available options studied so far, evidence shows that none of them is effective in the treatment of sleep disorders. This means that we are not able to conclude which is the best guidance to improve sleep quality in this type of population. eHealth interventions There is currently limited evidence suggesting that eHealth interventions may improve dietary sodium intake and fluid management for people with<unk>  <unk> . The findings are based on low certainty evidence of 43 studies. So, more large and higher quality research studies are needed to understand the impact of eHealth on the health of people with<unk> . Referral to a nephrologist Guidelines for referral to a nephrologist vary between countries. Most agree that nephrology referral is required by Stage 4<unk>  (when eGFR/1.73m2 is less than 30 ml/min; or decreasing by more than 3 ml/min/year). It may also be useful at an earlier stage (e.g.<unk> 3) when urine albumin-to-creatinine ratio is more than 30 mg/mmol, when blood pressure is difficult to control, or when hematuria or other findings suggest either a primarily glomerular disorder or secondary<unk>  amenable to specific treatment. Other benefits of early nephrology referral include proper education regarding options for kidney replacement therapy as well as pre-emptive transplantation, and timely workup and placement of an arteriovenous fistula in those people with<unk>  opting for future hemodialysis. Renal replacement therapy At stage 5<unk> , kidney replacement therapy is usually required, in the form of either dialysis or a kidney transplant. In<unk>  numerous uremic toxins accumulate in the blood. Even when ESKD (largely synonymous with<unk> 5) is treated with dialysis, the toxin levels do not go back to normal as dialysis is not that efficient. Similarly, after a kidney transplant, the levels may not go back to normal as the transplanted kidney may not work 100%. If it does, the creatinine level is often normal. The toxins show various cytotoxic activities in the serum and have different molecular weights, and some of them are bound to other proteins, primarily to albumin. Uremic toxins are classified into three groups as small water-soluble solutes, middle molecular-weight solutes, and protein-bound solutes. Hemodialysis with high-flux dialysis membrane, long or frequent treatment, and increased blood/dialysate flow has improved removal of water-soluble small molecular weight uremic toxins. Middle molecular weight molecules are removed more effectively with hemodialysis using a high-flux membrane, hemodiafiltration and hemofiltration. However, conventional dialysis treatment is limited in its ability to remove protein-bound uremic toxins.
Chronic kidney disease
Chronic liver disease
End stage pulmonary disease
Hypertensive kidney disease
Diabetes
Proteinopathy
Cirrhosis
Chronic critical illness