Treatment for Patients with GFR 44 (Stage 3B Chronic Kidney Disease)
ACE inhibitors or ARBs should be the cornerstone of treatment for patients with GFR 44, as they slow progression of kidney disease and reduce proteinuria. 1
First-Line Medications
Renin-Angiotensin System (RAS) Blockade
- ACE inhibitors (first choice) or ARBs (if ACE inhibitor not tolerated) should be initiated and titrated to maximum tolerated dose 1
- Start with low doses (e.g., lisinopril 2.5-5mg daily) and titrate upward every 1-2 weeks
- Monitor serum creatinine and potassium 1-2 weeks after initiation or dose changes 1, 2
- An initial rise in serum creatinine up to 30% is acceptable and expected 1, 3
- Discontinue only if creatinine rises >30% from baseline or hyperkalemia develops (K+ >5.6 mmol/L) 1, 3
Blood Pressure Management
- Target BP <130/80 mmHg if proteinuria <1g/day
- Target BP <125/75 mmHg if proteinuria >1g/day 1
- Multiple agents (typically 3-4) are usually required to achieve targets 1
Additional Medications Based on Clinical Presentation
If Edema Present
- Loop diuretics are preferred in CKD stage 3B:
- Bumetanide 0.5-2mg twice daily (preferred in moderate-severe CKD)
- Furosemide 40-80mg once or twice daily
- Torsemide 10-20mg once daily 2
- For resistant edema, add metolazone for sequential nephron blockade 2
- Restrict sodium intake to <2.0g/day to enhance diuretic effect 2
If Proteinuria Present
- Uptitrate ACE inhibitor/ARB to maximum tolerated dose to achieve proteinuria <1g/day 1
- Consider adding fish oil if proteinuria persists >1g/day despite optimized ACE inhibitor/ARB therapy 1
Monitoring and Follow-up
Renal function monitoring:
- Check serum creatinine and potassium 1-2 weeks after starting ACE inhibitor/ARB 1
- Then monitor every 3-6 months if stable
- More frequent monitoring if medication changes or intercurrent illness
Proteinuria assessment:
- Measure urine protein or albumin-to-creatinine ratio every 3-6 months
Blood pressure monitoring:
- Home BP monitoring encouraged
- Target BP as noted above
Important Precautions
- Avoid NSAIDs as they can worsen renal function and reduce efficacy of ACE inhibitors/ARBs 1, 2
- Avoid high protein diets (>1.3g/kg/day) as they increase albuminuria and accelerate kidney function loss 1
- Caution with contrast media - ensure adequate hydration before procedures 1
- Temporary discontinuation of ACE inhibitors/ARBs may be necessary during:
- Acute illness with volume depletion
- Diarrhea or vomiting
- Perioperative period for major surgery
- Severe hypotension (systolic BP <90 mmHg) 1
Special Considerations
- Hyperkalemia risk increases with ACE inhibitors/ARBs in CKD - monitor potassium levels closely 4
- Metabolic acidosis may develop - monitor serum bicarbonate and consider supplementation if <22 mEq/L 1
- Anemia - evaluate and treat if hemoglobin <10 g/dL 1
- Bone mineral disorders - monitor calcium, phosphate, PTH, and vitamin D levels 1
The early rise in serum creatinine with ACE inhibitors/ARBs (up to 30%) is associated with long-term renoprotection and should not prompt discontinuation unless it exceeds this threshold or significant hyperkalemia develops 1, 3.