proteinuria a low protein diet should be avoided because of the decrease in energy and growth in those with scn but limiting protein to the maximum daily requirement without exceeding it is beneficial in retaining kidney function. a low protein diet may be considered in end stage renal disease (esrd) alongside phosphate binders, and vitamin d, with the potential of using dialysis or kidney transplants. medications angiotensin-converting enzyme (ace) inhibitors and angiotensin receptor blockers (arbs) are beneficial in reducing proteinuria by 50% over a period of at least six months alongside a slight reduction in gfr but there is an unclear effect in overall ckd progression. if the medication is stopped then the symptoms return to similar levels to what it was before starting the medications. the lowering of nocturia has also been shown most likely from the decrease in gfr. this addition can be done regardless of baseline blood pressure. hydroxyurea is an antimetabolite which increases the production of hbf and decreases hbs synthesis leads to a decrease in hbs polymerization. one of the major concerns in using this medication is myelotoxicity and the development of tolerance over time. no significant effect on gfr but has potential benefit on proteinuria, specifically in the pediatric population. the use of hydroxyurea has been shown to decrease lactic hydrogenase and reticulocytes which is typically used as a predictor for ckd progression since it increases during hemolysis. since a decrease in hemolysis is correlated with positive scn outcomes, hydroxyurea may be beneficial in decreasing the risk of scn complications. erythropoietin stimulating agents (esas): during normal kidney function in those with scd, in response to anemia and hypoxia, erythropoietin synthesis is induced, causing increased erythropoietin compared to baseline. once gfr falls below 60 ml/min, erythropoietin production also declines and it is recommended to add on an esa to the current therapy; usually at higher doses. the target hemoglobin level should be lower than a normal patient with ckd because of the risk of vaso-occlusive events. even in esrd when those with scd become transfusion dependent, esas can still be used to increase the interval between infusions. if using esas, it is important to maintain iron levels to maintain the ability to produce red blood cells especially in those with ckd since sub-clinical bleeding is common, and there is decreased iron absorption. iv iron therapy is recommended if not receiving the necessary iron from blood transfusions but the dosing is unclear. diuretics are generally not used because of the decrease in blood volume which can cause a person with scd to have a sickle cell crisis but it can help treat circulatory overload; a condition caused from blood transfusions where there is too much fluid in the circulatory system. loop diuretics (furosemide) have also been used in treating severe hematuria by increasing urine flow.