Chronic renal failure secondary prevention

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Aarti Narayan, M.B.B.S [2]Sargun Singh Walia M.B.B.S.[3]


Effective measures for the secondary prevention of chronic renal failure include reducing progression, treating complication, and renal replacement therapy(RRT).

Secondary Prevention

Reduce Progression

  • Protective therapy most effective if initiated early, before Creatinine > 1.5-2.0 mg/dL
    • Treat Hypertension
    • Restrict Dietary Protein
      • Controversial – may decrease intraglomerular pressure.
      • Conflicting studies – some show benefit, others do not.
      • No significant adverse effects shown in large trial.
      • Recommendations
        • No restriction (> 0.8 g/kg/d) if GFR 25-55 mL/min.
        • Limit protein to 0.8 g/kg/d if progression or uremic symptoms.
        • Limit to 0.6 g/kg/d if severe renal insufficiency (GFR 13-25 mL/min).
      • Close follow-up by dietician given risk of malnutrition in this population.
    • Control Blood sugar:
      • Tight control (HbA1c < 7.0, [[Fasting blood sugar 70-120) reduces progression in DM I.
      • Unclear if as beneficial in DM II, but potentially helpful.

Treat complications

  • Volume Overload
  • Hyperkalemia
  • Management
    • Low potassium diet (< 60 mEq/d) once GFR < 15 mL/min.
    • Avoidance of salt substitutes (may contain potassium salts).
    • +/- loop diuretic
    • Low dose Kayexelate (5 g with meals) if needed.
  • Calcium/phosphate Abnormalities
    • Reduced renal synthesis Calcitriol/Vitamin D--low serum Calcium-- Secondary hyperparathyroidism.
    • (Occurs when GFR < 40 mL/min)
    • Reduced GFR--phosphate retention
    • Elevated parathyroid hormone (PTH)--mobilization of Calcium from bone; increased excretion phosphate.
    • Allows maintenance of normal Calcium/phosphate while GFR > 30 mL/min.
    • Causes renal osteodystrophy
    • Once GFR < 25-30 mL/min, hyperphosphatemia occurs
    • Therapy goals = normalize Calcium/Phosphate and maintain parathyroid hormone (PTH)< 200 (2-3x uln).
      • Calcium/Phosphate management should be initiated when Creatinine ~ 2.
      • Calcium x phosphate product should be < 60 to prevent met calcification.
      • Low phosphate diet: < 800 mg/d (challenging)
      • Calcium-based oral phosphate binders: Calcium acetate or Calcium carbonate with meals.
      • Avoid Aluminium-based phosphate binders except for acute therapy of high Calcium x Phosphate products.
      • Avoid Calcium citrate (increases gastrointestinal absorption of aluminum)
        • RenaGel = new non-Calcium/Aluminium-containing phosphate binder (cationic polymer).
          • (For patients who cannot tolerate Calcium carbonate or need additional agent)
        • Calcitriol 0.125-0.25 mg/d improves Calcium & Parathyroid hormone levels, decreases bone disease.
  • Metabolic Acidosis
    • Occurs when GFR < 25 mL/min due to inability to excrete H+ ions.
    • Underlying cause = impaired renal ammonia production and bicarbonate reabsorption.
    • Risk = bone buffering of acidosis--worsened Osteodystrophy via Calcium/phosphate loss.
    • Increased skeletal muscle breakdown--loss of lean body mass.
    • Therapy goal = bicarbonate > 22 mEq/L via alkali therapy (NaHCO3 0.5-1 mEq/kg/d)
  • Anemia

Plan for Renal Replacement Therapy (RRT)

Recent studies have shown no benefits of initiating early dialysis with improved patient survival. [2]However, advanced preparation for dialysis can help avoid complications like poorly functioning fistula for hemodialysis or malfunctioning peritoneal dialysis catheter, sepsis, bleeding and thrombosis.


  1. Lerche D, Kozlov MM, Markin VS (1987). "Electrostatic free energy and spontaneous curvature of spherical charged layered membrane". Biorheology. 24 (1): 23–34. PMID 3651580.
  2. Cooper BA, Branley P, Bulfone L; et al. (2010). "A randomized, controlled trial of early versus late initiation of dialysis". The New England Journal of Medicine. 363 (7): 609–19. doi:10.1056/NEJMoa1000552. PMID 20581422. Unknown parameter |month= ignored (help)

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