Treatment of Chronic Kidney Disease Stage 3
Adults with CKD stage 3 should be treated with a comprehensive approach targeting blood pressure control (<130/80 mmHg), using ACE inhibitors or ARBs as first-line therapy, along with appropriate management of metabolic abnormalities and cardiovascular risk factors. 1
Blood Pressure Management
- Blood pressure should be maintained below 130/80 mmHg in all patients with CKD stage 3 1
- ACE inhibitors are the first-line treatment for hypertension in CKD stage 3, particularly in those with albuminuria (≥300 mg/d or ≥300 mg/g albumin-to-creatinine ratio) to slow kidney disease progression 1
- If ACE inhibitors are not tolerated, ARBs (such as losartan) may be used as an alternative 1, 2
- Regular monitoring of kidney function and electrolytes is essential when initiating or adjusting doses of ACE inhibitors or ARBs due to potential for acute kidney injury and hyperkalemia 3
- Out-of-office blood pressure monitoring, particularly 24-hour assessment, is recommended to ensure adequate control 4
Diabetic Kidney Disease Management
- For patients with type 2 diabetes and CKD stage 3:
- Metformin can be used if eGFR is ≥45 mL/min/1.73 m² but should be used with caution and dose adjustment if eGFR is 30-45 mL/min/1.73 m² 1
- SGLT2 inhibitors should be considered as they reduce CKD progression (RR 0.66,95% CI 0.58-0.75) and heart failure hospitalizations (RR 0.64,95% CI 0.54-0.77) 1
- GLP-1 receptor agonists are beneficial for cardiovascular protection and may slow CKD progression 1
- Target HbA1c levels may need to be less intensive in CKD patients due to increased risk of hypoglycemia 1
Management of CKD-Related Complications
- Regular monitoring for common complications of CKD stage 3 should include 1:
- Electrolyte abnormalities (particularly potassium)
- Metabolic acidosis
- Anemia (hemoglobin and iron studies)
- Metabolic bone disease (calcium, phosphate, PTH, vitamin D)
Cardiovascular Risk Reduction
- Statin therapy is recommended for lipid management in CKD stage 3 patients, with a target LDL-C of ≤70 mg/dL (1.8 mmol/L) and reduction of at least 50% from baseline 4
- Higher doses of statins may be required as GFR declines 4
- Smoking cessation, weight management, regular physical exercise, and healthy dietary patterns are essential components of treatment 4, 5
Medication Considerations in CKD Stage 3
- Dose adjustment is necessary for many medications cleared by the kidneys 1
- Avoid nephrotoxic medications when possible 6
- For patients requiring contrast studies, preventive measures should be taken 1:
- Hydration with normal saline before contrast administration
- Use of low-osmolar or iso-osmolar contrast media
- Minimizing contrast volume
Monitoring and Follow-up
- Regular monitoring of kidney function (eGFR and albuminuria) every 6-12 months 1
- Assessment of blood pressure at each clinical visit 1
- Laboratory evaluations for CKD-related complications every 6-12 months 1
- Adjustment of medication dosages as kidney function changes 1, 3
Special Considerations
- Dual RAAS blockade (combining ACE inhibitors and ARBs) is not recommended due to increased risk of adverse effects without additional benefits 3
- Moderate reduction in dietary sodium intake enhances the efficacy of ACE inhibitors and ARBs 3
- In patients with heart failure and CKD, diuretics should be prescribed for volume overload, followed by ACE inhibitors or ARBs and beta-blockers 1
By implementing this comprehensive treatment approach, progression to end-stage renal disease can be significantly slowed, and cardiovascular complications—the leading cause of mortality in CKD patients—can be reduced 6, 5, 7.