Lifestyle CKD and CVD: Spot the differences

For Kidneys Sake podcast series is brought to you by Imperial College Healthcare NHS Trust and North West London Integrated Care Board (NWL NHS)

In this episode, nephrologists Professor Jeremy Levy and Dr Andrew Frankel, both from Imperial College Healthcare NHS Trust, explore strategies for managing Chronic Kidney Disease (CKD). The conversation focuses on essential lifestyle and health interventions to improve kidney health, particularly for patients newly diagnosed with CKD.

The hosts discuss how managing CKD should be viewed in the context of cardiovascular health. They highlight the importance of lifestyle changes, such as diet, exercise, smoking cessation, and weight management, which mirror approaches taken for cardiovascular risk. 

Both emphasise the role of patient engagement and education, encouraging patients to take ownership of their health by understanding their blood pressure, glucose levels, and the long-term impacts of CKD.

Blood pressure control is discussed in detail, with a focus on setting personalised targets based on factors such as age, comorbidities, and the severity of kidney disease. Frankel stresses the need for patients to self-monitor their blood pressure and understand their target ranges, typically between 120-140 systolic and less than 90 diastolic, but adjusted for albuminuria or frailty.

The episode also addresses managing diabetes in CKD patients, noting the importance of tight glucose control early in diabetes and the need to relax targets as CKD progresses to avoid hypoglycaemia.

Key takeaways include the critical role of lifestyle interventions, individualised blood pressure management, and tailored glycaemic control. Future episodes will cover specific medications and more advanced treatment strategies for CKD.

We hope you enjoyed this episode.

Resource Links:
NICE GUIDELINES [NG203] chronic kidney disease: assessment and management Overview | Chronic kidney disease: assessment and management | Guidance | NICE

Northwest London CKD guidelines for primary care Chronic kidney disease (nwlondonicb.nhs.uk)

The purpose of this podcast is to inform and educate health care professionals working in the primary care and community setting. The content is evidence based and consistent with NICE guidelines and North West Guidelines available at the time of publication.

The content of this podcast does not constitute medical advice and it is not intended to function as a substitute for a healthcare practitioner’s judgement.

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Transcript

Welcome to North West London Kidney Care Podcast. A bitesize podcast where Chronic Kidney Disease Management is made easy for healthcare professionals in primary care.

Jeremy Levy

Hello, it's a great pleasure to be here! I'm Professor Jeremy Levy, I'm a consultant kidney specialist and nephrologist from Imperial College Healthcare.

Andrew Frankel

Hello there, Jeremy, and I'm one of your colleagues, of course! I'm Andrew Frankel, also a kidney doctor from Imperial College Healthcare NHS Trust.

Jeremy Levy

It's a real pleasure to be here. Andrew and I are going to be having a conversation about managing Chronic Kidney Disease over a series of these podcasts, and it's very exciting to be able to do this, and we hope this will be useful and informative.

So today, in this podcast, we're going to be covering the management strategy that can be adopted in somebody who's been diagnosed with chronic kidney disease. We're going to think about this in three different ways, over three separate podcasts, so they're all nice and simple, and straightforward, and short. This first podcast will cover lifestyle, blood pressure, and glucose glycaemic control. And then future podcasts will think specifically about some of the drugs we're using, that many of you will be familiar with, such as those blocking the renin-angiotensin system, and, of course the SGLT2inhibitors. And then we'll go on from there and cover further topics.

So in this podcast, we really want to talk about lifestyle, lifestyle interventions that will promote good kidney health in everybody of course, but especially in people with chronic kidney disease.

So Andrew, when faced with patients who've just been diagnosed with chronic kidney disease, how do you start to think about developing a sort of a management strategy for them, to help with their kidney disease?

Andrew Frankel

Well, Jeremy, I think that the prime action that one needs to take is to ensure that the person with CKD is engaged, and educated, and activated - that they understand what CKD means, and what are the implications of CKD, because unless you go from that starting point, that individual cannot make changes to their lifestyle, or embrace any self care strategies.

And I would start with the fact that we think about CKD as kidney disease, but of course, as you and I both know, its major impact relates to its association with cardiovascular disease. So you could start from the basis of actually thinking of this as a cardiovascular disease, and the foundation of management of CKD is therefore aligned to your approach to people with high cardiovascular risk. I don't know what advice you give people Jeremy, in that situation?

Jeremy Levy

I agree completely. It is all about trying to move away from just being a kidney issue, to being one about cardiovascular disease. I'll tell you what I do in a moment, you tell us what you do first.

Andrew Frankel

Okay, so I think that you need to ensure that the person understands what they need to do in relation to their diet, their exercise, smoking, and weight loss. All the things you would do in an individual who's got, say, diabetes, or cardiovascular disease, it's exactly the same for CKD. Complex dietary intervention really only occurs with people with more advanced kidney disease.

Statin therapy, therefore, is a cornerstone of CKD management, because you're trying to reduce that risk of cardiovascular disease, and that should be considered for all people with CKD stages three to five.

Jeremy Levy

So I completely agree with you, and I think that issue about diet and exercise is really, really important. We both get loads of people, don't we? Who have Googled kidney disease and diet, and all they can remember is those extremes of diet for people on dialysis, and I have to repeatedly remind them that that's really not relevant for them, and what's really important is a standard healthy diet, with actually plenty of fruit and vegetables and relatively low salt, relatively low meat protein, but not to be looking up those extreme diets, that are really only  for people on dialysis.

You mentioned it, but stopping smoking is critical, isn't it? And even though figures are relatively low in the UK, a significant number of people still smoke. And there's good evidence that stopping smoking not only lowers cardiovascular risk, but also progression of kidney disease. And as you know, I bang on about exercise all the time, and I think we can be specific. You know, that standard advice of trying to get up to 30 minutes, four or five times a week, and a mix of aerobic and weight bearing exercise is really good for cardiovascular health, and kidney health. So all those things I think are really important.

Andrew Frankel

Yeah, well we both give the same messages when we see people with kidney disease, which is encouraging that we are starting from the same point.

Blood pressure, for me, is a very key part of the management strategy for CKD. But for me, one of the key points is to try and give that person ownership of their blood pressure. So of course, you set targets that are appropriate for age and comorbidity, but you also have to ensure that the person understands what the meaning of blood pressure is. I teach everyone with CKD in my clinic, to undertake self monitoring of blood pressure, teach them what it means, understand when to get concerned, how frequently to do the tests, and when to draw sequences of abnormal results to their primary care physician or clinician.

Jeremy Levy

That's really, really sensible. But do you have specific targets that you actually give people when you're aiming for them? Because people do need numbers, don't they, even if they're not used to looking at them?

Andrew Frankel

Oh, yes, you must give a target. There are very well defined specific targets, defined by NICE, that we reiterate in our North West London CKD guidelines. The targets are not a ‘less than’ for systolic, but a range. So it's really important, that it's about range, because actually, from a kidney health point of view, kidneys are a bit like the story of Goldilocks. They don't like the blood pressure too hot, and they don't like the blood pressure too cold, so you've got to get it at a range. And we broadly suggest that you aim for a systolic range of 120 to 140

with a diastolic of less than 90. So 120 to 140 with a diastolic of less than 90. However, if they're significant albuminuria, and by that, I mean the ACR is greater than 70. You need to tighten that. And that would push you to try and aim for a target of between 110 and 130, and a diastolic of 80.

Of course, you've got to personalise these blood pressure targets, so if the person is frail or multi morbid, the targets should be liberalised and adjusted upwards. So if you had a person in front of you of 85, even with albuminuria, it would be perfectly reasonable to run a systolic blood pressure of 120 to 145. So clear targets, systolic ranges, adjusting it downwards if the person has albuminuria, and upwards if they are frail or multi morbid.

Jeremy Levy

That sounds really sensible. And again, it's exactly what I do. And the other bit, I always try and remember of course, is if you've got younger people, say between 30 and 40, which, of course, is very young, with potentially 50 years of life expectancy ahead of them, getting things like blood pressure down is critical. Because if they've got, you know, moderate or even mild chronic kidney disease with GFRs of let's say 45, you want to preserve kidney function through their life, which is going to be a very long time, and also reduce their risks of strokes, heart attacks, and cardiovascular disease.

And so as you said, tightening control in younger people with heavier proteinuria, is really important because of that length of their life ahead of them, isn't it? And as individual professionals, often we can forget that, that we might only be engaged with them for 10 or 20 years, but they've got 50 years of life, and that's a very long time in which to prevent, again, not just renal failure, but all those cardiovascular risks. And that's very different from the frailer, elderly people who are already in their 70s and 80s. So yeah, I think absolutely looking at the person in front of you, in deciding the best strategy.

You haven't mentioned specific drugs, and I know we're going to talk about that in a later episode. But of course, classically, we're using a lot of Renia, renin angiotensin blockers, aren't we? But fundamentally for this, we'll cover this in a later brief talk, isn't that right?

Andrew Frankel

That's correct. We'll look at the actual medicines, although I would suggest to you, Jeremy, the medicines are the easier part of the management, and much of what we've said in this podcast is the key to actually achieving improvements in kidney health, in the long term.

Jeremy Levy

That's absolutely right. So clearly, a lot of these people who've got chronic kidney disease, also have diabetes. So what do you think about the management of the glycaemic control in people who've got diabetes and chronic kidney disease? Because clearly, then we've got these two issues, and it is quite complex, isn't it?

Andrew Frankel

Yes, it's not simple, but it's important to get the key message across that diabetes is the major driver of the growth in the number of people with CKD that we are seeing in the UK, and indeed worldwide.

What we do know, is that in the earlier stages of diabetes, very good, very tight blood glucose control, getting HbA1Cs down to near normal, provides significant long term benefit in relation to all the microvascular and indeed macrovascular complications of diabetes. So getting that HbA1C down over the first 5 to 10 years after the individual has developed diabetes (I do appreciate we sometimes don't know what year zero is), but that is a key strategy.

However, once that individual has developed any form of cardiorenal complication of their diabetes, they've got albuminuria, their GFR is down, or they've had a cardiovascular event, what we know is that good glycemic control is still important in terms of retinopathy and some complications, but it doesn't slow down progression of CKD, as much as you get with the benefit in the early years. And indeed, we become a little more concerned about hypoglycaemia, because hypos are associated with poor cardiovascular outcomes.

So it's tight control for the first 10 years or so. Then you take your foot off the accelerator a little bit, and certainly by the time the person has got Cardiorenal complications or any form of CKD, I aim for less tight, aiming for an HbA1C of sort of 53 to 63, rather than that drive towards 48.

Jeremy Levy

That's really, really helpful. And again, we haven't been mentioning any specific medicines here, because we're going to cover some of those in later talks, aren't we? And overall, for now, this was about concepts and how to think about glycemic control.

So Andrew, I think that's been really, really helpful, hasn't it? And most of our patients, in fact, are diabetic. In our patch of London, almost 50% of people with chronic kidney disease have diabetes. It's a major driver for chronic kidney disease, but clearly lots of the other patients don't have diabetes.

Overall, I think we've covered lots of things here, haven't we?

My three take-home messages from this seem to be that all the normal things for cardiovascular risk, diet, exercise, stopping smoking, and lifestyle are critically important for chronic kidney disease.

Blood pressure is really important, and we're no longer saying, you know, less than, and getting it as low as possible, we're giving people ranges. And classically, that's about 120 - 140, with diastolic less than 90, but individualising depending on their level of proteinuria, and their age. And glycemic control early in diabetes is really quite tight, but once they've got chronic kidney disease and later on, we really don't want hypoglycemia, so it is slightly more relaxed.

We want people to be really engaged in this. So buying their own blood pressure machines, measuring their own blood pressure at home can be really, really important, and writing down the numbers. And all of that makes a big difference, doesn't it, to engaging people with managing and being aware of and reducing all their risks.

Andrew Frankel

And I really also like the point you made, which is so important - when you sit down with a person with CKD, you're talking to them not about just the now, and the results they have today, but about their future and if they are younger (but I would even say if they're my age), you would have got another 20 years or 25 years of life expectancy. They want to understand how they can live that with the best quality of life, and by making changes now, particularly in relation to their kidney health, they can do that.

Jeremy Levy
Andrew, you're absolutely right. I don’t know about the ‘even your age’(!), you and I are of similar ages, and absolutely 20 or 30 years ahead, all very important!

I think we should stop there. I think that's been a really useful conversation. I hope everybody out there has enjoyed it.

Thank you for listening, we hope you enjoyed this episode. All information is fully consistent with NICE and North West London guidelines. You can find out more in the show notes and contact us with any suggestions or questions, to do so, send us a text using the text function at the top of your show notes.
Up next, we are covering pharmacological therapy of CKD SGLT2 inhibitors, or as I like to call them, kidney treatments that also help diabetes. Everyone recognises their benefit, but the real issue is to gain the confidence to identify and minimise the potential risks. What are the practical tips to prescribe SGLT2 in CKD with or without type 2 diabetes? When to adjust sulphonylureas and insulin? How to explain the risk of fourniers gangrene to patients? 

Thanks for listening, please subscribe to the show, and we will see you next time!