What is the initial treatment plan for a patient with chronic kidney disease (CKD) stage three?

Initial Treatment Plan for Chronic Kidney Disease Stage 3

The initial treatment plan for chronic kidney disease (CKD) stage 3 should focus on blood pressure control with an ACE inhibitor or ARB, statin therapy, and lifestyle modifications to slow disease progression and reduce cardiovascular risk.

Blood Pressure Management

• Target blood pressure should be less than 130/80 mmHg for patients with CKD stage 3 1
• First-line therapy should include either:
  • Angiotensin-converting enzyme (ACE) inhibitors 1
  • Angiotensin II receptor blockers (ARBs) if ACE inhibitors are not tolerated 1
• Diuretics are commonly needed as part of combination therapy to achieve target blood pressure 2
• Blood pressure should be monitored regularly, preferably with 24-hour ambulatory devices for accurate assessment 1

Cardiovascular Risk Reduction

• For patients aged ≥50 years with CKD stage 3 (eGFR <60 ml/min/1.73 m²), statin or statin/ezetimibe combination therapy is strongly recommended (Grade 1A) 1
• For patients aged 18-49 years with CKD stage 3, statin therapy is suggested if they have:
  • Known coronary disease
  • Diabetes mellitus
  • Prior ischemic stroke
  • Estimated 10-year cardiovascular risk >10% 1
• Low-dose aspirin is recommended for secondary prevention in patients with established cardiovascular disease 1
• Consider PCSK-9 inhibitors for patients with indications for their use 1

Dietary and Lifestyle Modifications

• Recommend a plant-based "Mediterranean-style" diet in addition to pharmacological therapy 1
• Sodium restriction to help control blood pressure 1
• Limit alcohol, meats, and high-fructose corn syrup intake 1
• Regular aerobic exercise as tolerated 3
• Smoking cessation counseling if applicable 4

Metabolic Abnormalities Management

• Monitor and treat metabolic acidosis if present 5
• Assess and manage mineral bone disorders:
  • Monitor calcium, phosphorus, and parathyroid hormone levels
  • Treat hyperphosphatemia if present
  • Evaluate vitamin D status and supplement if deficient 5, 4

Anemia Management

• Evaluate iron status before and during treatment 6
• Administer supplemental iron when serum ferritin is <100 mcg/L or transferrin saturation is <20% 6
• Consider erythropoiesis-stimulating agents (ESAs) if hemoglobin <10 g/dL, with careful monitoring to avoid exceeding 11 g/dL 6

Medication Adjustments and Avoidance

• Review all medications for appropriate dosing in CKD stage 3 1
• Avoid nephrotoxic medications, particularly:
  • NSAIDs
  • Certain antibiotics requiring dose adjustment
  • Metformin should be used with caution or avoided if serum creatinine ≥1.5 mg/dL in men or ≥1.4 mg/dL in women 1, 4

Monitoring and Follow-up

• Regular monitoring of kidney function (eGFR and albuminuria) every 3-6 months 4
• Assess for complications of CKD including hyperkalemia, metabolic acidosis, and anemia 4
• Consider referral to nephrology for patients with:
  • Rapid decline in kidney function
  • Significant albuminuria (≥300 mg/g)
  • Difficult-to-control hypertension
  • Complex metabolic abnormalities 4

Special Considerations

• For patients with diabetes, glycemic control is important but requires careful monitoring due to increased risk of hypoglycemia in CKD 1
• For patients with atrial fibrillation, non-vitamin K antagonist oral anticoagulants (NOACs) are preferred over warfarin, with appropriate dose adjustments based on kidney function 1