Nephroprotective medications
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Nephroprotective Medications in Chronic Kidney Disease
Renin-Angiotensin System Inhibitors (ACEi/ARB) and Mineralocorticoid Receptor Antagonists
Renin-angiotensin system inhibitors, such as angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB), are foundational nephroprotective medications. They not only lower blood pressure but also reduce proteinuria and slow the progression of chronic kidney disease (CKD) in both diabetic and non-diabetic patients. Spironolactone, a mineralocorticoid receptor antagonist, also provides nephroprotection independent of its blood pressure-lowering effects 25.
Sodium-Glucose Cotransporter 2 Inhibitors (SGLT2i)
SGLT2 inhibitors, originally developed for diabetes, have shown significant nephroprotective effects. They reduce the risk of declining glomerular filtration rate (GFR) and are effective in both diabetic and non-diabetic CKD. These benefits are seen in adults and, according to early studies, may extend to pediatric patients as well, with dapagliflozin showing a stabilizing effect on kidney function and albuminuria in children 12357. SGLT2 inhibitors are now recommended for people with diabetes and CKD, and their use is expanding to broader CKD populations.
Glucagon-Like Peptide 1 Receptor Agonists (GLP1-RA)
GLP1 receptor agonists, another class of antidiabetic drugs, have demonstrated nephroprotective properties, particularly in reducing the risk of macroalbuminuria. They are recommended for patients with diabetes and CKD, especially those at increased cardiovascular risk 135.
Disease-Specific and Supportive Therapies
Other nephroprotective strategies include correcting metabolic acidosis with sodium bicarbonate and using disease-specific treatments for particular kidney diseases. Effective control of hypertension, diabetes, hyperlipidemia, and metabolic acidosis is essential for nephroprotection in patients with CKD, including those with rheumatic diseases 235.
Nephroprotection in Drug-Induced Kidney Injury
Several medications and natural products have been studied for their ability to protect the kidneys from drug-induced toxicity. Antioxidants, calcium channel blockers, and agents that inhibit tubular reuptake or promote excretion have shown promise in preclinical studies for preventing aminoglycoside-induced nephrotoxicity . Telmisartan, an antihypertensive, has been shown to protect against cisplatin-induced kidney injury by reducing inflammation and oxidative stress . Naringin, a citrus flavonoid, has demonstrated protective effects against methotrexate-induced renal toxicity in animal models by reducing oxidative stress and inflammation .
Medication Management and Misconceptions
It is important to note that some medications often labeled as "nephrotoxic," such as ACEi, ARB, SGLT2i, and metformin, actually provide substantial kidney and cardiac benefits. Stopping these medications without proper clinical judgment, especially during acute illness, can lead to harm. Individualized, evidence-based management is crucial to optimize outcomes in CKD patients .
Conclusion
Nephroprotective medications play a critical role in slowing CKD progression and improving patient outcomes. Key drug classes include ACEi, ARB, SGLT2i, GLP1-RA, and mineralocorticoid receptor antagonists, with additional support from disease-specific therapies and metabolic management. Careful, individualized medication management is essential to maximize benefits and avoid unnecessary discontinuation of protective therapies.
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