What are the management strategies for Chronic Kidney Disease (CKD) stage 3A with Impaired renal function?

From the Guidelines

Management of CKD stage 3a should focus on a comprehensive treatment strategy to reduce the risks of progression and associated complications, as recommended by the KDIGO 2024 clinical practice guideline 1. The primary approach includes:

• Blood pressure control with a target of <130/80 mmHg, typically using ACE inhibitors (like lisinopril 10-40 mg daily) or ARBs (such as losartan 25-100 mg daily) as first-line agents, which provide renoprotection beyond blood pressure control by reducing intraglomerular pressure and proteinuria 1.
• Dietary modifications, including:
  • Sodium restriction to <2g daily
  • Moderate protein intake (0.8g/kg/day)
  • Potassium restriction if levels are elevated
• Regular monitoring, including:
  • Quarterly assessment of kidney function (eGFR, creatinine)
  • Electrolytes
  • Urinary albumin-to-creatinine ratio
• Glycemic control is crucial for diabetic patients, targeting HbA1c of 7-8% 1.
• SGLT2 inhibitors like empagliflozin (10-25 mg daily) or dapagliflozin (5-10 mg daily) should be considered as they provide cardiorenal protection independent of glycemic effects 1.
• Cardiovascular risk reduction through statin therapy is recommended regardless of baseline lipid levels 1.
• Lifestyle modifications, including:
  • Smoking cessation
  • Weight management
  • Regular exercise
  • Avoiding nephrotoxic medications (NSAIDs, aminoglycosides) Early nephrology referral should be considered for progressive decline in kidney function, resistant hypertension, or significant proteinuria 1.

From the Research

Management of CKD Stage 3A

Blood Pressure Targets

• The ideal blood pressure goal for patients with CKD stage 3A is less than 140/90 mm Hg, as suggested by 2 and 3.
• However, some studies recommend a target of less than 130/80 mm Hg in patients with CKD who have significant proteinuria, as stated in 3 and 4.
• A target systolic BP of 120 to 130 mm Hg and diastolic BP of 70 to 80 mm Hg may yield the greatest benefit while avoiding most of the adverse cardiovascular outcomes associated with lower levels of BP, as found in 2.

Antihypertensive Therapy

• Combination of angiotensin II receptor antagonist with calcium channel blocker or diuretic can be used as antihypertensive therapy for patients with CKD, as compared in 5.
• Angiotensin receptor blockers (ARBs) may be considered as an alternative to angiotensin-converting enzyme (ACE) inhibitors, as they have equal outcome efficacy but fewer adverse events, as discussed in 6.

Monitoring and Adverse Effects

• Careful laboratory monitoring is necessary to assess for adverse effects of therapy, such as electrolyte abnormalities and decreased eGFR, as noted in 4.
• Measuring blood pressure accurately and assessing patient preferences and concurrent medical conditions are also important, as mentioned in 4.