Hello Sarah, 

Great question. Yes, start any patient with DM and HTN on an ACEI (losartan) or ARB, even if they are at Stage 1, 2 or 3. After starting the medication on the lower dose, check potassium level 1 week later to make sure they are not hyperkalemic and their Cr is not elevated too much. You will see a Cr rise of at leat 0.3mg/dL or slightly more (but ideally not >1mg/dL) after starting ACEI or ARB. The ACEI/ARB should show improvement in proteinuria by 1 month and ideally you can go up on the ACEI/ARB dose to get the proteinuria goal to be 0.5g to 1gm daily on a 24hr urine protein test. Starting ACEI/ARB at Stage 4b or 5 disease is generally not recommended becasue it would mean that the patients have already progressed further in kidney failure where dialysis will be imminent unless patients have a kidney transplant. If the patient was started on ACEI/AR during Stage 3 and are now at Stage 5, then I will continue that ACEI/ARB until I notice worsening hyperkalemia. 

For diabetic patient, the latest recommendations are also to try a SGLT2 inhibitor if the patient continues to have uncontrolled glycemia and/or proteinuria and  if patients also have heart disease (heart failure, CAD, CVA, etc). SGLT2 inhibitors work great and have relatviely low side effects and research studies have shown that they are cardioprotective. 

A good reference from KDIGO: https://kdigo.org/wp-content/uploads/2020/01/Christopher-Wilcox.pdf

Thanks much!

Sarah

Hello Achin, 

great questions, we plan to have a lecture on management of them in the future. Please refer to KDIGO guidelines:  https://kdigo.org/wp-content/uploads/2017/02/2017-KDIGO-CKD-MBD-GL-Update.pdf   (re: PTH and phosphatemia after page 16,17).

In general, we recommend keeping serum phosphatase around 3-5.5mg/dl using phosphate binders (sevelemer carbonate and calcium acetate). Note, that if patients have high coronary artery disease or hypercalcemia, then avoid phosphate binder with calcium (so instead give sevelemer). If any patient has history of malabsorption (i.e. cystic fibrosis, ileostomy, gastric surgery/short bowel syndrome, inflammatory bowel disease), then give the phosphate binder with calcium. Also, patients need to eat low phosphate diet (ie. <800mg). 

For hyperparathyroid, the first step is to confirm if it is PRIMARY or SECONDARY related. Check serum calcium, ionized calcium, serum Vitamin D 250H, intact PTH and rPTH, serum phosphorus. If it is primary hyperparathyroid, then the treatment is removal of the parathyroid (ex. surgery). If it is secondary hyperparathyroid. Secondary hyperparathyoid needs to be treated because it causes bone-mineral dysfunction. For the PTH goals, please refer to guidelines posted  http://kidneyfoundation.cachefly.net/professionals/KDOQI/guidelines_bone/guide1.htm#table15.   Treatment iinvolves correcting the hyperphospatemia and/or vitaminD deficiency. Then, if patient continues to have secondary hyperparathyroism, treat with sensipar. Caution use of Cinacalcet if serum calcium is low (i.e <7).

Ex of medications--

•Active vitamin D/ Vitamin D analog (active vitamin D): Calcitriol, Doxercalciferol, Paricalcitol

      Side effects: hypercalcemia, hyperphosphatemia

•Calcium-sensing Receptor Agonist (Etelcalcetide - IV, Cinacalcet - PO)

       Side effects: hypocalcemia, GI symptoms

Parathyroidectomy recommended in severe refractory secondary hyperparathyroidism