What is the initial treatment approach for stage 3b Chronic Kidney Disease (CKD)?

From the Guidelines

The initial treatment approach for stage 3b Chronic Kidney Disease (CKD) should focus on optimizing blood pressure control using renin-angiotensin system inhibitors (RASI), such as angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs), to slow disease progression and manage complications. According to the 2021 KDIGO clinical practice guideline 1, RASI therapy is recommended for people with high blood pressure, CKD, and severely increased albuminuria, as it reduces both cardiovascular event rates and kidney end points. Key aspects of treatment include:

• Blood pressure control: targeting levels below 120 mm Hg, with RASI as the initial therapy choice
• Dietary modifications: sodium restriction, moderate protein intake, and potassium restriction if necessary
• Glycemic control for diabetic patients: aiming for HbA1c around 7%
• Consideration of SGLT2 inhibitors for patients with diabetes or heart failure to slow CKD progression
• Regular monitoring of kidney function, electrolytes, and metabolic parameters every 3-6 months
• Addressing complications such as anemia, mineral bone disorders, and metabolic acidosis to preserve remaining kidney function and prevent disease progression. The use of RASI in CKD without diabetes with severely increased albuminuria is supported by four placebo-controlled RCTs showing clear evidence of reduction in the risks for both kidney failure and cardiovascular events 1.

From the FDA Drug Label

The RENAAL study was a randomized, placebo-controlled, double-blind, multicenter study conducted worldwide in 1513 patients with type 2 diabetes with nephropathy (defined as serum creatinine 1.3 to 3.0 mg/dL in females or males ≤60 kg and 1.5 to 3. 0 mg/dL in males >60 kg and proteinuria [urinary albumin to creatinine ratio ≥300 mg/g]). Treatment with losartan resulted in a 16% risk reduction in this endpoint (see Figure 4 and Table 4) Treatment with losartan also reduced the occurrence of sustained doubling of serum creatinine by 25% and ESRD by 29% as separate endpoints, but had no effect on overall mortality (see Table 4).

The initial treatment approach for stage 3b Chronic Kidney Disease (CKD) may involve the use of angiotensin II receptor antagonists such as losartan, as it has been shown to reduce the risk of doubling of serum creatinine and end-stage renal disease (ESRD) in patients with type 2 diabetes and nephropathy 2.

• The treatment should focus on blood pressure control and reducing proteinuria.
• Losartan has been shown to reduce proteinuria by an average of 34% and slow the decline in glomerular filtration rate.
• However, it is essential to note that the study was conducted in patients with type 2 diabetes and nephropathy, and the results may not be directly applicable to all patients with stage 3b CKD.

From the Research

Initial Treatment Approach for Stage 3b Chronic Kidney Disease (CKD)

The initial treatment approach for stage 3b CKD involves a combination of non-pharmacological strategies and pharmacological interventions.

• Non-pharmacological strategies include dietary and lifestyle adjustments, such as a plant-dominant, low-protein, and low-salt diet to mitigate glomerular hyperfiltration and preserve renal function 3.
• Pharmacological interventions include renin-angiotensin-aldosterone pathway modulators and SGLT2 inhibitors to preserve kidney function by reducing intraglomerular pressure independently of blood pressure and glucose control 3, 4.
• Managing CKD-associated cardiovascular risk, minimizing the risk of infection, and preventing acute kidney injury are also crucial interventions for these patients 3, 5.

Key Components of Treatment

The treatment approach for stage 3b CKD should include:

• Cardiovascular risk reduction, such as statins and blood pressure management 5.
• Treatment of albuminuria, such as angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers 5.
• Avoidance of potential nephrotoxins, such as nonsteroidal anti-inflammatory drugs 5.
• Adjustments to drug dosing, such as many antibiotics and oral hypoglycemic agents 5.
• Monitoring for complications of CKD, such as hyperkalemia, metabolic acidosis, hyperphosphatemia, vitamin D deficiency, secondary hyperparathyroidism, and anemia 5.

Special Considerations

For older patients with CKD stage 3b or higher, the European Renal Best Practice Group recommends a comprehensive approach to management, taking into account the patient's frailty, comorbidities, and functional status 6.

• The treatment approach should be individualized and tailored to the patient's specific needs and goals 6.
• Patients at high risk of CKD progression should be promptly referred to a nephrologist for further evaluation and management 5.