Abstract
Childhood chronic kidney disease commonly progresses toward end-stage renal failure, largely independent of the underlying disorder, once a critical impairment of renal function has occurred. Hypertension and proteinuria are the most important independent risk factors for renal disease progression. Therefore, current therapeutic strategies to prevent progression aim at controlling blood pressure and reducing urinary protein excretion. Renin-angiotensin-system (RAS) antagonists preserve kidney function not only by lowering blood pressure but also by their antiproteinuric, antifibrotic, and anti-inflammatory properties. Intensified blood pressure control, probably aiming for a target blood pressure below the 75th percentile, may exert additional renoprotective effects. Other factors contributing in a multifactorial manner to renal disease progression include dyslipidemia, anemia, and disorders of mineral metabolism. Measures to preserve renal function should therefore also comprise the maintenance of hemoglobin, serum lipid, and calcium-phosphorus ion product levels in the normal range.
Highlights
Childhood chronic kidney disease commonly progresses toward end-stage renal failure, largely independent of the underlying disorder, once a critical impairment of renal function has occurred
As a consequence of the mechanistic insights in renal disease progression obtained by experimental work, several principal renoprotective strategies have emerged in recent years (Fig. 1)
We review current treatment strategies to slow renal disease progression in childhood chronic kidney disease (CKD)
Summary
Pediatr Nephrol (2008) 23:705–716 of CKD progression in humans [3,4,5]. The renin-angiotensin system (RAS) is intrinsically involved in the process, and other potential contributors include genetic background, renal anemia, altered mineral homeostasis, dyslipidemia, chronic inflammation, and oxidative stress as well as general cardiovascular risk factors such as diabetes, smoking, and obesity. As a consequence of the mechanistic insights in renal disease progression obtained by experimental work, several principal renoprotective strategies have emerged in recent years (Fig. 1) These are based mainly on clinical evidence established in adult patients, but growing evidence supports their efficacy in children. Efficient control of blood pressure and minimization of proteinuria appear as the two most important measures to preserve residual kidney function Other issues, such as prevention and treatment of renal anemia, uremic dyslipidemia, and disorders of mineral metabolism, have an experimental basis, their clinical importance is less clear to date. The European Study Group for Nutritional Treatment of Chronic Renal Failure in Childhood demonstrated that in CKD children, a systolic blood pressure greater than 120 mmHg was associated with a significantly faster glomerular filtration rate (GFR) decline [9]. In the most recent guidelines by the Joint National Committee in the US (JNC7) [13] and the Guidelines of the European Hypertension Society [14], 120/80 mmHg has been defined as the upper limit of the ‘optimal’ blood pressure range, when proteinuria is present, and any blood pressure > 130/80 in CKD
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