From the Guidelines
The management of stage 3 Chronic Kidney Disease (CKD) should focus on slowing disease progression and preventing complications, with a strong emphasis on blood pressure control using ACE inhibitors or ARBs, as recommended by the American College of Physicians (1).
Key Recommendations
- Blood pressure control: Target less than 130/80 mmHg using ACE inhibitors or ARBs like lisinopril (10-40 mg daily) or losartan (50-100 mg daily), which provide renoprotection beyond blood pressure control (1).
- Glycemic control: For diabetic patients, aim for HbA1c of 7-8%, with SGLT2 inhibitors like empagliflozin (10-25 mg daily) or dapagliflozin (5-10 mg daily) preferred due to their kidney-protective effects.
- Regular monitoring: Check creatinine, eGFR, electrolytes, and urine albumin-to-creatinine ratio every 3-6 months.
- Lifestyle modifications: Limit dietary sodium to less than 2 grams daily, moderate protein intake to 0.8 g/kg/day, maintain adequate hydration, exercise regularly, and avoid nephrotoxic medications like NSAIDs.
- Vaccinations: Patients should receive pneumococcal and annual influenza vaccinations.
- Cardiovascular risk factors: Addressing these factors is important as CKD increases cardiovascular disease risk.
- Referral to a nephrologist: Recommended when eGFR declines rapidly (>5 mL/min/1.73m² annually) or for management of complications like resistant hypertension, significant proteinuria, or electrolyte disturbances.
Rationale
The American College of Physicians recommends selecting pharmacologic therapy that includes either an angiotensin-converting enzyme inhibitor or an angiotensin II-receptor blocker in patients with hypertension and stage 1 to 3 CKD (1). Additionally, statin therapy is recommended to manage elevated low-density lipoprotein in patients with stage 1 to 3 CKD (1). These recommendations are based on a systematic evidence review evaluating the published literature on this topic from 1985 through November 2011.
From the Research
Guidelines for Stage 3 Chronic Kidney Disease (CKD)
The guidelines for stage 3 CKD focus on retarding the progression of renal disease. Key points include:
- Blood pressure control is crucial in reducing cardiovascular risk and renal disease progression 2
- A blood pressure target of less than 140/90 mm Hg is recommended for patients with CKD stage III and IV 2
- For patients with CKD and proteinuria of more than 1 g/day, a target systolic BP of 120 to 130 mm Hg and diastolic BP of 70 to 80 mm Hg may yield the greatest benefit 2
- The use of angiotensin receptor blockers (ARBs) such as losartan may provide effective renoprotection without changing blood pressure and is generally safe and well tolerated in normotensive patients with nondiabetic stage 3 CKD 3
- Intensive blood pressure control may not be beneficial in patients with stage 3 CKD, but may be beneficial in those with stages 4-5 CKD 4
Treatment and Management
Treatment and management of stage 3 CKD include:
- The use of renin-angiotensin system inhibitors (RASIs), such as angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) 5, 6
- Discontinuation of ACEI/ARB therapy is associated with a higher risk of death and incident end-stage kidney disease (ESKD) 5
- RAS blockers may present significant renoprotective effects in CKD patients with very high albuminuria, but randomized trials specifically addressing their use in patients with advanced CKD are scarce 6