What is the initial management for a patient with Chronic Kidney Disease (CKD) stage 3?

Initial Management of Chronic Kidney Disease Stage 3

The initial management of CKD stage 3 should focus on blood pressure control with a target of less than 130/80 mmHg using ACE inhibitors or ARBs as first-line therapy, along with cardiovascular risk reduction through statin therapy, lifestyle modifications, and avoidance of nephrotoxic medications. 1, 2

Blood Pressure Management

• Target blood pressure should be less than 130/80 mmHg for all patients with CKD stage 3 2, 1
• First-line pharmacotherapy should include an ACE inhibitor or ARB, particularly when albuminuria is present (≥300 mg/day) 2
• An ACE inhibitor is reasonable to slow kidney disease progression in CKD stage 3 or higher 2
• If ACE inhibitor is not tolerated, an ARB may be used as an alternative 2, 1
• Monitor for postural hypotension regularly when treating with BP-lowering medications 2
• Up to 30% increase in serum creatinine after starting ACE inhibitors or ARBs is acceptable and not a reason to discontinue therapy 1

Cardiovascular Risk Reduction

• Statin therapy is recommended for all patients with CKD stage 3 aged ≥50 years 1, 3
• For patients aged 18-49 years, statin therapy is suggested if they have coronary disease, diabetes, prior ischemic stroke, or estimated 10-year cardiovascular risk >10% 1
• SGLT2 inhibitors should be considered as they have shown significant benefits in slowing CKD progression 1, 4
• Low-dose aspirin is recommended for secondary prevention in patients with established cardiovascular disease 1

Dietary and Lifestyle Modifications

• Encourage moderate-intensity physical activity for at least 150 minutes per week 5, 4
• Recommend a plant-based "Mediterranean-style" diet 5, 1, 4
• Advise sodium restriction to help control blood pressure 1, 4
• Encourage weight management to achieve optimal body mass index 5, 4
• Complete cessation of tobacco products is strongly recommended 5, 4
• Limit alcohol consumption to avoid binge drinking which can increase risk of CKD progression 4

Medication Management

• Review all medications for appropriate dosing in CKD stage 3 1, 6
• Avoid nephrotoxic medications, particularly NSAIDs 1, 6
• 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
• For patients with diabetes, follow KDIGO Diabetes Guidelines, including use of GLP-1 receptor agonists where indicated 5, 3

Regular Monitoring

• Monitor serum creatinine, potassium, and albuminuria regularly 5, 1
• Assess for complications of CKD such as hyperkalemia, metabolic acidosis, hyperphosphatemia, vitamin D deficiency, secondary hyperparathyroidism, and anemia 6
• Reassess cardiovascular risk factors every 3-6 months 5, 6
• Consider 24-hour ambulatory blood pressure monitoring for accurate assessment 1

Referral Considerations

• Consider referral to nephrology for patients with CKD stage 3 who have:
  • Rapid decline in GFR 2, 7
  • Significant albuminuria (>300 mg/day) 2, 7
  • Refractory hypertension (requiring 4 or more medications) 2
  • Persistent electrolyte abnormalities 2
  • Recurrent nephrolithiasis 2
  • Hereditary kidney disease 2

Common Pitfalls to Avoid

• Do not discontinue ACE inhibitors or ARBs prematurely due to initial creatinine elevation (up to 30% increase can be acceptable) 1
• Do not delay implementation of SGLT2 inhibitors in appropriate patients 1
• Avoid using the combination of an ACE inhibitor and an ARB together due to increased risk of adverse events 2
• Do not overlook the importance of lifestyle modifications alongside pharmacological therapy 4, 8
• Remember that most patients with stage 3 CKD die from cardiovascular causes rather than progressing to end-stage renal disease, making cardiovascular risk reduction paramount 2, 3