From the Guidelines
The treatment approach for a patient with stage 3 chronic kidney disease and a GFR of 35 mL/min/1.73m² should focus on slowing disease progression and managing complications, with a primary goal of controlling blood pressure to levels below 130/80 mmHg using ACE inhibitors or ARBs, as recommended by the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline 1.
Key Components of Treatment
- Blood pressure control: targeting levels below 130/80 mmHg using ACE inhibitors (like enalapril 5-40 mg daily or lisinopril 10-40 mg daily) or ARBs (such as losartan 25-100 mg daily), which provide renoprotective effects beyond blood pressure control 1.
- Glycemic control for diabetic patients: aiming for HbA1c of 7-8%, potentially using SGLT2 inhibitors like empagliflozin 10-25 mg daily or dapagliflozin 5-10 mg daily, which have shown kidney-protective benefits.
- Dietary modifications: restricting sodium to 2-3 g/day, moderating protein intake to 0.8 g/kg/day, and limiting phosphorus and potassium if levels are elevated.
- Regular monitoring: quarterly assessments of kidney function, electrolytes, and blood pressure, with screening for complications like anemia, metabolic bone disease, and acidosis.
Nephrology Referral
Nephrology referral is appropriate at this stage to establish specialized care, as recommended by the American College of Physicians guideline for the treatment of stage 1 to 3 chronic kidney disease 1.
Additional Considerations
- The combination of an ACE inhibitor and an ARB should be avoided due to reported harms demonstrated in several large cardiology trials and in 1 diabetic nephropathy trial 1.
- Further GFR decline should be investigated and may be related to other factors, including volume contraction, use of nephrotoxic agents, or renovascular disease 1.
From the Research
Staging and Treatment of Chronic Kidney Disease (CKD)
- CKD is typically staged based on the Glomerular Filtration Rate (GFR), with stage 3 CKD indicating a GFR of 30-59 mL/min/1.73 m^2 2.
- A patient with a GFR of 35 would be classified as having stage 3 CKD.
Treatment Approach for Stage 3 CKD
- The treatment approach for stage 3 CKD typically involves a combination of lifestyle modifications and medications to slow disease progression and manage related health conditions 3, 2.
- Medications such as angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) are commonly used to slow CKD progression and reduce proteinuria 3, 4, 5.
- ACE inhibitors have been shown to be effective in reducing the risk of kidney events, cardiovascular events, and all-cause death in patients with non-dialysis CKD stages 3-5 5.
Benefits and Risks of ACE Inhibitors
- ACE inhibitors have been shown to have renoprotective effects in patients with diabetic and non-diabetic renal disease, likely due to their ability to reduce systemic vascular resistance and lower filtration pressure 6.
- However, ACE inhibitors can also increase the risk of hyperkalemia, cough, and hypotension, particularly in patients with advanced diabetic kidney disease 5, 6.
- The benefits of ACE inhibitors in patients with CKD must be carefully weighed against the potential risks, and dosages should be carefully titrated with monitoring of renal function and serum potassium levels 6.
Monitoring and Follow-up
- Regular monitoring of GFR, proteinuria, and other health indicators is essential to assess the effectiveness of treatment and adjust the treatment plan as needed 2.
- Patients with stage 3 CKD should be closely monitored for signs of disease progression, such as a decline in GFR or an increase in proteinuria, and for related health conditions such as hypertension and cardiovascular disease 2, 5.