What are the management recommendations for patients with Chronic Kidney Disease (CKD) stage 3?

Management of Chronic Kidney Disease Stage 3

Patients with CKD stage 3 should be managed with a comprehensive approach including blood pressure control targeting <130/80 mmHg, preferably with ACE inhibitors or ARBs, lifestyle modifications, and regular monitoring of kidney function and complications. 1

Blood Pressure Management

Blood pressure control is a cornerstone of CKD management:

• Target BP goal: <130/80 mmHg for patients with CKD stage 3, especially those with albuminuria ≥30 mg/24h 2
• First-line medications:
  • ACE inhibitors or ARBs are recommended for patients with albuminuria ≥300 mg/24h 2
  • ACE inhibitors or ARBs are reasonable for patients with albuminuria 30-300 mg/24h 2
• Monitoring after starting RAS blockade:
  • Check serum creatinine and potassium within 2-4 weeks of initiation or dose increase 1
  • Continue ACEi/ARB unless serum creatinine rises by more than 30% within 4 weeks 1
  • Do not use ACEi and ARB together (increased risk without additional benefit) 1

Lifestyle Modifications

• Physical activity: 150 minutes of moderate-intensity exercise per week 1, 3
• Diet recommendations:
  • Protein intake: 0.8 g/kg/day (avoid high-protein diets) 2, 1
  • Sodium restriction: <2 g sodium per day (<5 g salt/day) 1
  • Follow a plant-dominant, Mediterranean-style diet high in vegetables, fruits, whole grains, fiber, legumes 1, 4
  • Reduce meat consumption and use low-fat or nonfat dairy products 2
• Weight management: Achieve optimal BMI (20-25 kg/m²) through weight loss if overweight/obese 1, 5
• Smoking cessation: Complete avoidance of tobacco products 1

Metabolic and Cardiovascular Risk Management

• Diabetes management:

  • Consider metformin as first-line therapy if eGFR >45 mL/min/1.73m² 1
  • SGLT2 inhibitors recommended for T2D with CKD and eGFR ≥20 ml/min/1.73 m² 1
  • GLP-1 receptor agonists for those who haven't achieved glycemic targets despite metformin and SGLT2i 1

• Lipid management:

  • Statins recommended for adults ≥50 years with CKD stage 3 1
  • Consider statin/ezetimibe combination for enhanced cardiovascular protection 1

Monitoring and Follow-up

• eGFR and albuminuria monitoring:

  • CKD stage 3 with normal albuminuria (A1): Monitor 1-2 times per year
  • CKD stage 3 with moderate albuminuria (A2): Monitor 2-3 times per year
  • CKD stage 3 with severe albuminuria (A3): Monitor 3-4 times per year 1

• Complication screening:

  • Monitor and manage phosphate, calcium, PTH, and vitamin D levels 1
  • Check for metabolic acidosis (serum bicarbonate <22 mmol/L) and consider oral bicarbonate supplementation 1
  • Evaluate iron status and supplement if ferritin <100 mcg/L or transferrin saturation <20% 1
  • Monitor for hyperkalemia, particularly in patients on RAS inhibitors 1

Nephrology Referral Considerations

Consider nephrology referral for:

• Rapid decline in eGFR (>5 mL/min/1.73 m²/year) 1
• Albuminuria ≥300 mg/24 hours 2
• Persistent proteinuria with protein excretion >1 g/d 2
• Refractory hypertension (requiring 4+ medications) 2
• Persistent electrolyte abnormalities 2
• Uncertainty about diagnosis or etiology of CKD 2

Important Cautions

• Avoid nephrotoxic medications: NSAIDs, aminoglycosides, and other nephrotoxins 1
• Medication adjustments: Review all medications and adjust doses for kidney function 1
• Do not discontinue ACEi/ARB when eGFR falls below 30 ml/min/1.73 m² unless there are specific contraindications 1
• Monitor for postural hypotension regularly when treating with BP-lowering drugs 2
• Avoid overreliance on HbA1c in advanced CKD as it may be less accurate 1

Cardiovascular Risk Reduction

Patients with CKD stage 3 have significantly increased cardiovascular risk compared to those without CKD 6. Therefore:

• Aggressive cardiovascular risk factor management is essential
• Consider low-dose aspirin for secondary prevention in those with established cardiovascular disease 1
• Address all modifiable risk factors including hypertension, diabetes, dyslipidemia, and smoking 7

By implementing this comprehensive management approach, progression to advanced CKD can be delayed and cardiovascular complications reduced, significantly improving patient outcomes and quality of life.