How to manage a patient with impaired renal function at a G3 level?

Management of Patients with G3 CKD

For patients with G3 chronic kidney disease (GFR 30-59 mL/min/1.73m²), medication management should prioritize dose adjustment of renally excreted drugs, temporary discontinuation of nephrotoxic medications during acute illness, and careful monitoring of kidney function. 1

Medication Management

Drug Dosing and Adjustments

• Take GFR into account when prescribing medications, as many drugs require dose adjustment in CKD G3 1
• For drugs with narrow therapeutic indices, consider methods based on cystatin C or direct GFR measurement for more accurate dosing 1
• When calculating drug doses for patients significantly larger or smaller than average, convert estimated GFR to absolute clearance (mL/min, not mL/min/1.73m²) 1
• Monitor drug levels regularly for potentially nephrotoxic agents such as lithium and calcineurin inhibitors 1

Specific Medication Considerations

Renin-Angiotensin System Blockers (ACEi/ARBs)

• ACEi/ARBs are recommended as first-line therapy for patients with both hypertension and proteinuria 1
• Monitor renal function and electrolytes closely when initiating or adjusting doses 2
• Do not stop ACEi/ARB with modest and stable increases in serum creatinine (up to 30%) 1
• Temporarily discontinue during serious intercurrent illness that increases AKI risk 1

Metformin

• Continue metformin in patients with GFR ≥45 mL/min/1.73m² (G3a) 1
• Review use in patients with GFR 30-44 mL/min/1.73m² (G3b) and consider dose reduction proportional to GFR 1
• Advise patients to temporarily discontinue metformin during periods of increased AKI risk (surgery, angiography, acute illness) 1

NSAIDs

• Avoid NSAIDs when possible as they are among the most commonly prescribed nephrotoxic medications in CKD patients 3
• If required, use for shortest duration possible and monitor renal function closely 1

"Sick Day Rules"

• Temporarily discontinue potentially nephrotoxic and renally excreted drugs during serious intercurrent illness 1
• Medications to hold include: ACEi/ARBs, diuretics, NSAIDs, metformin, lithium, and digoxin 1
• Resume medications once the acute illness resolves and renal function returns to baseline 1

Cardiovascular Risk Management

Lipid Management

• For adults ≥50 years with G3 CKD, statin or statin/ezetimibe combination therapy is recommended 1
• For adults 18-49 years with G3 CKD, consider statin therapy if they have coronary disease, diabetes, prior stroke, or elevated cardiovascular risk 1
• Consider a plant-based "Mediterranean-style" diet in addition to lipid-modifying therapy 1

Antiplatelet Therapy

• Low-dose aspirin is recommended for secondary prevention in patients with established cardiovascular disease 1
• Consider alternative antiplatelet therapy (e.g., P2Y12 inhibitors) when aspirin is not tolerated 1

Management of CKD Complications

Hyperkalemia

• Implement an individualized approach for hyperkalemia management including dietary and pharmacologic interventions 1
• Provide dietary advice to limit intake of foods rich in bioavailable potassium for patients with history of hyperkalemia 1
• Consider potassium-wasting diuretics to allow continued use of RAS inhibitors 1

Hyperuricemia and Gout

• Treat symptomatic hyperuricemia with uric acid-lowering therapy 1
• Prefer xanthine oxidase inhibitors over uricosuric agents 1
• For acute gout, use low-dose colchicine or glucocorticoids rather than NSAIDs 1

Edema Management

• Use loop diuretics as first-line therapy for edema, with twice-daily dosing preferred 1
• Restrict dietary sodium to <2.0 g/day 1
• For resistant edema, combine loop diuretics with thiazide diuretics for synergistic effect 1
• Monitor for adverse effects of diuretics including hypokalemia, hyponatremia, and volume depletion 1

Monitoring and Follow-up

• Regularly monitor kidney function, electrolytes, and drug levels 1
• Screen for and manage proteinuria, which has prognostic value 1
• Monitor for cardiovascular complications, as CKD patients have increased cardiovascular risk 1
• Evaluate for signs of peripheral arterial disease regularly 1

Special Considerations

Contrast Media

• For patients requiring contrast studies, use the lowest possible radiocontrast dose 1
• Provide adequate hydration with saline before, during, and after contrast procedures 1
• Measure GFR 48-96 hours after contrast administration 1
• Consider alternatives to gadolinium-based contrast media, especially in patients with more advanced CKD 1

Over-the-Counter Medications

• Advise patients to seek medical or pharmacist advice before using over-the-counter medicines or nutritional protein supplements 1
• Recommend against using herbal remedies 1

Cancer Treatment

• Do not deny necessary cancer therapies, but adjust cytotoxic drug doses according to GFR 1
• For anticancer drugs with significant renal clearance (≥30% of administered dose), dose adjustment is necessary 4
• Provider awareness of a patient's CKD status is associated with lower odds of nephrotoxic medication use 3