From the Guidelines
Management of stage 3a Chronic Kidney Disease (CKD) should prioritize blood pressure control, glycemic control, and lifestyle modifications to slow disease progression and address associated complications. The primary recommendations are:
- Blood pressure control: Target BP <130/80 mmHg using ACE inhibitors or ARBs as first-line agents (e.g., lisinopril 10-40 mg daily or losartan 50-100 mg daily) 1.
- Glycemic control in diabetics: Aim for HbA1c <7% using metformin as the first-line treatment, and consider SGLT2 inhibitors or GLP-1 RAs as add-on therapy to reduce risks of CKD progression, CVD events, and hypoglycemia 1.
- Lifestyle modifications: Encourage smoking cessation, regular exercise, and maintaining a healthy weight.
- Diet: Limit sodium intake to <2g/day and protein intake to 0.8g/kg/day. Avoid excessive potassium and phosphorus.
- Manage complications:
- Anemia: Monitor hemoglobin; consider iron supplementation or erythropoiesis-stimulating agents if Hb <10 g/dL.
- Mineral bone disorder: Monitor calcium, phosphorus, and PTH levels; consider vitamin D supplementation.
- Cardiovascular risk: Assess lipid profile and consider statin therapy.
- Regular monitoring: Check eGFR and albuminuria every 6-12 months.
- Avoid nephrotoxic agents: Minimize use of NSAIDs and adjust medication doses as needed.
These interventions aim to preserve kidney function by controlling hypertension, reducing proteinuria, and managing metabolic disturbances. Early management can significantly slow CKD progression and reduce the risk of cardiovascular complications, which are the leading cause of mortality in CKD patients. According to the most recent and highest quality study 1, metformin should be considered the first-line treatment for all patients with type 2 diabetes, including those with CKD, and SGLT2 inhibitors and GLP-1 RAs should be considered for patients who require another drug added to metformin to attain target A1C or cannot use or tolerate metformin.
From the Research
Management of Stage 3a Chronic Kidney Disease (CKD)
The management of stage 3a CKD involves the use of various medications to slow the progression of the disease and reduce the risk of cardiovascular complications.
- Angiotensin-Converting Enzyme Inhibitors (ACEi) and Angiotensin Receptor Blockers (ARB): These classes of antihypertensive drugs have been shown to have beneficial effects on kidney outcomes and survival in people with CKD 2, 3. However, the effectiveness of ACEi and ARB in patients with stage 1 to 3 CKD who do not have diabetes mellitus is less certain.
- Combination Therapy: A study found that combination therapy with losartan and hydrochlorothiazide was more effective in reducing proteinuria and blood pressure in hypertensive patients with stage 3 CKD compared to losartan alone 4.
- Aldosterone Antagonists: The addition of aldosterone antagonists to ACEi and/or ARB may be beneficial in reducing proteinuria in patients with CKD, but it increases the risk of hyperkalaemia 5.
- Blood Pressure Control: Controlling blood pressure is crucial in the management of CKD, and ACEi and ARB are recommended as the first choice for blood pressure control 6.
Key Findings
- The available evidence on the effectiveness of ACEi and ARB in patients with stage 1 to 3 CKD who do not have diabetes mellitus is of low certainty and high risk of bias 2, 3.
- Combination therapy with losartan and hydrochlorothiazide may be more effective in reducing proteinuria and blood pressure in hypertensive patients with stage 3 CKD 4.
- Aldosterone antagonists may be beneficial in reducing proteinuria in patients with CKD, but the risk of hyperkalaemia needs to be carefully monitored 5.