From the Guidelines
The initial management approach for an elderly patient with Stage 3 CKD should focus on slowing disease progression and addressing modifiable risk factors, with a primary goal of optimizing blood pressure control to a target of <130/80 mmHg, as supported by the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline 1.
Key Management Strategies
- Optimize blood pressure control with a target of <130/80 mmHg, preferably using ACE inhibitors (like lisinopril 5-40 mg daily) or ARBs (such as losartan 25-100 mg daily) as first-line agents, due to their renoprotective effects beyond blood pressure control 1.
- Implement dietary modifications including sodium restriction to <2g/day, moderate protein intake (0.8g/kg/day), and potassium restriction if hyperkalemia is present, as recommended for persons with early stages of CKD 1.
- Manage dyslipidemia with statins (atorvastatin 10-20 mg daily) to reduce cardiovascular risk, and avoid nephrotoxic medications including NSAIDs, aminoglycosides, and contrast agents when possible.
- Regular monitoring should include quarterly assessment of kidney function (serum creatinine, eGFR), electrolytes, and urinary albumin-to-creatinine ratio, with careful monitoring of physical and kidney function during incremental BP reduction 1.
Additional Considerations
- Glycemic control is essential for diabetic patients, targeting HbA1c around 7-8% while avoiding hypoglycemia in the elderly.
- Address metabolic complications such as anemia, bone mineral disorders, and acidosis if present.
- Lifestyle modifications including smoking cessation, weight management, and regular physical activity are important adjuncts to the comprehensive management approach.
Evidence-Based Recommendations
The 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline 1 and the SPRINT study results support the benefits of intensive BP management in patients with CKD, including those with stage 3 to 4 CKD, with a lower target of <130/80 mmHg. However, it is essential to acknowledge the potential risks and benefits of intensive BP treatment in elderly patients with CKD, particularly those with additional comorbidities and evidence of frailty 1.
From the Research
Initial Management Approach for Elderly Patients with Stage 3 CKD
The initial management approach for an elderly patient with Stage 3 Chronic Kidney Disease (CKD) involves several key components:
- Early detection and diagnosis through a kidney health check, which includes blood pressure measurement, a blood test for serum creatinine and estimated glomerular filtration rate (eGFR), and a urine test for albumin:creatinine ratio 2
- Control of blood pressure to recommended levels with appropriate medications, with a target blood pressure of less than 140/90 mm Hg 3
- Treatment guided by the patient's stage of CKD, based on kidney function (eGFR) and kidney damage (degree of albuminuria)
Medications for CKD Management
Medications such as angiotensin-converting-enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB) may be used to prevent the progression of CKD:
- ACEi and ARB have been shown to prevent kidney failure and reduce the risk of cardiovascular events in patients with CKD 4, 5, 6
- ARB may be preferred for diabetic patients with albuminuria due to their renoprotective effects 6
Monitoring and Follow-up
Regular monitoring and follow-up are crucial to ensure that the patient's condition is stable and that any changes in their condition are promptly addressed:
- Regular blood tests to monitor kidney function and electrolyte levels
- Regular urine tests to monitor albuminuria and kidney damage
- Regular blood pressure checks to ensure that blood pressure is within the recommended range
Lifestyle Modifications
Lifestyle modifications can also play an important role in managing CKD:
- A healthy diet that is low in salt, sugar, and fat
- Regular exercise to help control blood pressure and improve overall health
- Quitting smoking and limiting alcohol consumption to reduce the risk of cardiovascular events and kidney damage