What are the primary management strategies for a patient with Chronic Kidney Disease (CKD) Stage III?

Management of Chronic Kidney Disease (CKD) Stage III

Blood Pressure Management

The primary management strategy for CKD Stage III should focus on strict blood pressure control with a target of <130/80 mmHg, particularly for patients with albuminuria >300 mg/day. 1

• For patients with CKD Stage III and albuminuria ≥30 mg/day, target blood pressure should be ≤130/80 mmHg 1
• For patients with CKD Stage III without significant albuminuria (<30 mg/day), a target of <140/90 mmHg is appropriate 2
• Angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARBs) should be first-line therapy, especially in patients with albuminuria 1
• ACEi/ARBs should be titrated to the highest approved dose that is tolerated 1
• Monitor serum creatinine, potassium, and blood pressure within 2-4 weeks of initiating or increasing dose of ACEi/ARB 1
• Continue ACEi/ARB therapy unless serum creatinine rises by more than 30% within 4 weeks of treatment initiation 1

Albuminuria Management

• Regularly assess urinary albumin excretion to stratify risk and guide therapy 2
• ACEi or ARB therapy should be initiated in all patients with diabetes, hypertension, and albuminuria 1
• Even for patients with albuminuria and normal blood pressure, treatment with ACEi or ARB may be considered 1
• Reduction in urinary albumin/protein excretion is a key therapeutic target 1

Cardiovascular Risk Reduction

• Initiate statin therapy for patients over 50 years with eGFR <60 ml/min/1.73 m² 2
• Consider low-dose aspirin for patients with established cardiovascular disease 2
• For patients with diabetes and CKD, consider SGLT2 inhibitors when eGFR is ≥30 ml/min/1.73 m² 1
• Implement smoking cessation strategies 1
• Encourage regular physical activity and exercise 1

Medication Management

• Avoid nephrotoxic medications, particularly NSAIDs 2
• Review all medications regularly, including over-the-counter and herbal supplements 2
• Adjust medication dosages based on GFR for renally cleared drugs 2
• Loop diuretics may be helpful for patients with substantial residual renal function 1
• Consider nocturnal dosing of antihypertensive medications to avoid interference with dialysis and ultrafiltration 1

Dietary Recommendations

• Restrict dietary sodium to <2,300 mg/day 2
• Recommend dietary protein intake of 0.8 g/kg body weight per day 2
• Consider a plant-based "Mediterranean-style" diet to reduce cardiovascular risk 2
• Maintain appropriate glycemic control in diabetic patients 2

Monitoring and Evaluation

• Monitor eGFR, electrolytes, and medication levels every 3-5 months 2
• Screen for complications including hypertension, volume overload, electrolyte abnormalities, metabolic acidosis, anemia, and metabolic bone disease 2
• Perform thorough medication reviews periodically and at transitions of care 2

Management of Complications

• Screen for and manage anemia, metabolic acidosis, and metabolic bone disease 2
• Monitor for gout and consider low-dose colchicine or glucocorticoids rather than NSAIDs for acute gout management 2
• For patients requiring contrast-enhanced imaging:
  • Ensure hydration with normal saline before contrast administration 1
  • Use low-osmolar or iso-osmolar contrast media 1
  • Minimize contrast volume 1
  • Consider hydration with sodium bicarbonate before contrast administration 1

Referral to Specialist Care

• Consider nephrology referral for patients with eGFR <45 ml/min/1.73 m² 2
• Immediate referral is warranted for uncertainty about etiology, difficult management issues, or rapidly progressing kidney disease 2

Patient Education

• Educate patients about expected benefits and risks of medications 2
• Emphasize the importance of medication adherence and regular monitoring 2
• Provide structured education to engage patients in self-management of their disease 1