Key Considerations When Reviewing Stage 3 Chronic Kidney Disease
When reviewing a patient with stage 3 chronic kidney disease (CKD), focus on medication management, comorbidity assessment, and monitoring for disease progression to reduce mortality and improve quality of life.
Assessment of Kidney Function and Disease Progression
- Evaluate estimated glomerular filtration rate (eGFR) at least monthly after initial stabilization 1
- Monitor for annual eGFR decline - early diagnosis and intervention significantly reduces decline from 3.20 ml/min/1.73 m² to 0.74 ml/min/1.73 m² 2
- Assess albuminuria/proteinuria to stratify risk of progression
- Document CKD diagnosis formally, as delayed diagnosis is associated with:
- 40% increased risk of progression to stage 4/5 CKD
- 63% increased risk of kidney failure
- 8% increased risk of cardiovascular events 2
Medication Management
Antihypertensive Therapy
- Strongly recommend ACE inhibitors or ARBs as first-line therapy for patients with hypertension and stage 3 CKD 1
- Adjust dosing based on kidney function:
- For ACE inhibitors: Start at lower doses and titrate based on blood pressure response and potassium levels
- For ARBs: Similar approach as ACE inhibitors with careful monitoring
Glycemic Control in Diabetic CKD
- Adjust antihyperglycemic medications based on eGFR:
- Metformin: No dose adjustment if eGFR > 45 ml/min/1.73 m²; reduce dose if eGFR 30-45 ml/min/1.73 m²; discontinue if eGFR < 30 ml/min/1.73 m² 1
- Sulfonylureas: Use with caution; prefer glipizide over glyburide (contraindicated in advanced CKD) 1
- DPP-4 inhibitors: Adjust dose based on eGFR (except linagliptin which requires no adjustment) 1
- Monitor for hypoglycemia, especially with insulin and sulfonylureas
- Consider insulin dose reduction (25-30% lower basal insulin for type 1 diabetes with CKD stage 3) 1
Lipid Management
- Strongly recommend statin therapy for management of elevated LDL in stage 3 CKD 1
- Adjust statin dosing based on kidney function to minimize adverse effects
Monitoring for Complications
Anemia Management
- Screen for anemia regularly
- Evaluate iron status before and during treatment with erythropoiesis-stimulating agents (ESAs)
- For patients requiring ESAs:
Electrolyte and Metabolic Abnormalities
- Monitor serum calcium, phosphorus, and parathyroid hormone
- Assess for metabolic acidosis and consider bicarbonate supplementation if indicated
- Check potassium levels regularly, especially in patients on RAAS blockers
Cardiovascular Risk Reduction
- Assess and manage traditional cardiovascular risk factors
- Monitor for volume overload and adjust diuretic therapy accordingly
- Screen for and manage hypertension aggressively
Nephrotoxin Avoidance
- Review all medications for potential nephrotoxicity
- Avoid NSAIDs when possible
- Adjust medication dosing based on eGFR
- Educate patients about over-the-counter medications to avoid
Nutritional Considerations
- Assess for protein-energy wasting and malnutrition 4
- Consider dietary modifications:
- Moderate protein restriction (0.8 g/kg/day)
- Sodium restriction for hypertension management
- Potassium and phosphorus restriction as needed based on laboratory values
Vaccination Recommendations
- Ensure up-to-date vaccinations:
- Seasonal influenza
- Pneumococcal vaccines
- Hepatitis B
- Tetanus 4
Planning for Disease Progression
- Discuss prognosis and treatment options for advanced CKD
- Consider early nephrology referral for patients with:
- Rapid progression (decline in eGFR > 5 ml/min/1.73 m² per year)
- Significant albuminuria (>300 mg/g)
- Comorbidities that increase risk of progression 5
- Begin education about renal replacement therapy options
- Preserve peripheral veins for potential future vascular access 4
Follow-up Planning
- Schedule regular follow-up visits based on eGFR stability and comorbidities
- More frequent monitoring for patients with:
- Unstable kidney function
- Multiple comorbidities
- Recent medication changes
By systematically addressing these key considerations when reviewing patients with stage 3 CKD, clinicians can optimize management to slow disease progression, reduce complications, and improve patient outcomes.