What is the workup and management for Stage 3 Chronic Kidney Disease (CKD)?

From the Guidelines

For stage 3 kidney disease workup and management, start with a comprehensive evaluation including laboratory tests and imaging studies, and implement strict blood pressure control, aiming for a target of <130/80 mmHg, using an ACE inhibitor or angiotensin receptor blocker (ARB) as first-line antihypertensive therapy, as recommended by the American College of Physicians 1. The management of stage 3 chronic kidney disease (CKD) should focus on slowing disease progression and addressing complications.

• Order a complete metabolic panel, complete blood count, urinalysis, and urine albumin-to-creatinine ratio to assess kidney function and detect any potential complications.
• Calculate the estimated glomerular filtration rate (eGFR) using the CKD-EPI equation to determine the severity of kidney disease.
• Perform renal ultrasound to assess kidney size and structure. Implementing strict blood pressure control is crucial in managing stage 3 CKD, as it can help slow disease progression and reduce the risk of cardiovascular complications.
• First-line antihypertensive therapy should include an ACE inhibitor or ARB, such as lisinopril 10-40 mg daily or losartan 25-100 mg daily, as recommended by the American College of Physicians 1.
• Monitor potassium levels closely when using these medications, as they can increase the risk of hyperkalemia. Addressing cardiovascular risk factors is also essential in managing stage 3 CKD.
• Prescribe a statin for lipid management, such as atorvastatin 10-80 mg daily, regardless of baseline cholesterol levels, as recommended by the American College of Physicians 1.
• For diabetic patients, maintain tight glycemic control with a target HbA1c of <7%. Dietary modifications can also play a crucial role in managing stage 3 CKD.
• Recommend sodium restriction to <2 grams per day and protein intake of 0.8 g/kg/day, as recommended by the American Heart Association 1.
• Encourage regular exercise and smoking cessation to reduce cardiovascular risk factors. Monitor and treat anemia if present, considering erythropoiesis-stimulating agents when hemoglobin falls below 10 g/dL.
• Assess and manage mineral bone disorder by monitoring calcium, phosphorus, and parathyroid hormone levels, and consider vitamin D supplementation if deficient. Avoid nephrotoxic medications, including NSAIDs and certain antibiotics, to prevent further kidney damage. Follow up every 3-6 months with repeat laboratory tests to monitor disease progression and adjust management as needed.
• Refer to a nephrologist if eGFR declines rapidly (>5 mL/min/1.73 m2 per year) or for complex management issues.

From the FDA Drug Label

Control of high blood pressure should be part of comprehensive cardiovascular risk management, including, as appropriate, lipid control, diabetes management, antithrombotic therapy, smoking cessation, exercise, and limited sodium intake Losartan is indicated for the treatment of diabetic nephropathy with an elevated serum creatinine and proteinuria (urinary albumin to creatinine ratio ≥300 mg/g) in patients with type 2 diabetes and a history of hypertension

The management of Stage 3 Chronic Kidney Disease (CKD) may involve:

• Blood pressure control as part of comprehensive cardiovascular risk management
• Lipid control
• Diabetes management
• Antithrombotic therapy
• Smoking cessation
• Exercise
• Limited sodium intake
• Losartan may be used in patients with diabetic nephropathy and elevated serum creatinine and proteinuria 2

From the Research

Workup for Stage 3 Chronic Kidney Disease (CKD)

• The workup for Stage 3 CKD involves assessing the patient's kidney function, blood pressure, and presence of proteinuria 3, 4, 5
• Estimating the glomerular filtration rate (GFR) using the modification of diet in renal disease (MDRD) formula is essential in assessing kidney function 3
• Blood pressure management is critical, with a target blood pressure of less than 140/90 mm Hg 5
• Proteinuria assessment is also crucial, with a target of less than 500 mg/day 3

Management of Stage 3 CKD

• The management of Stage 3 CKD involves a multifaceted approach, including:
  • Reduction of proteinuria using angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB) 6, 3, 7
  • Blood pressure control using ACEi, ARB, or other antihypertensive agents 3, 4, 5
  • Salt restriction diet and diuretics (furosemide, spironolactone) 3
  • Body weight reduction, cigarette smoking cessation, and allopurinol therapy 3
  • Avoidance of non-steroidal anti-inflammatory agents, acetaminophen, bisphosphonates, and oral estrogens 3
• Combination therapy with ACEi or ARB and a low-dose diuretic (hydrochlorothiazide) may be effective in reducing proteinuria and blood pressure 7
• Patients with Stage 3 CKD may require supervision by a nephrologist to assess disease progression and need for renal replacement therapy 3