Primary Treatment Approach for Chronic Kidney Disease Stage 3A
The primary treatment approach for CKD stage 3A should include ACE inhibitors or ARBs as first-line therapy, with a target blood pressure of <130/80 mmHg, along with lifestyle modifications and management of comorbidities. 1, 2
Blood Pressure Management
- ACE inhibitors or ARBs are the first-line therapy for hypertension in CKD stage 3A, especially in patients with albuminuria (≥300 mg/d or ≥300 mg/g albumin-to-creatinine ratio) 2, 1
- Target blood pressure should be <130/80 mmHg for most patients with CKD 2
- If blood pressure goals are not achieved with ACE inhibitors/ARBs alone, add dihydropyridine calcium channel blockers and/or diuretics 1, 3
- For Black patients with CKD, initial therapy should include a thiazide-type diuretic or calcium channel blocker, either alone or in combination with a RAS blocker 1
- Monitor serum creatinine and potassium within 2-4 weeks after initiation or dose increase of ACE inhibitors or ARBs 1
- Continue therapy unless serum creatinine rises by more than 30% within 4 weeks of initiation or dose increase 1, 2
Medication Dosing in CKD 3A
- For ACE inhibitors like lisinopril, no dose adjustment is required in patients with creatinine clearance >30 mL/min 4
- Start with lower doses in patients at risk for hypotension and titrate up as tolerated 4, 3
- Avoid NSAIDs as they can worsen kidney function and interfere with the effectiveness of antihypertensive medications 2
Management of Comorbidities
Lipid Management
- For adults aged ≥50 years with eGFR <60 ml/min per 1.73 m², treatment with a statin or statin/ezetimibe combination is recommended 2
- For adults aged 18-49 years with CKD, statin treatment is suggested for those with coronary disease, diabetes mellitus, prior ischemic stroke, or estimated 10-year incidence of coronary death or nonfatal MI >10% 2
Diabetes Management
- For patients with diabetic CKD, SGLT2 inhibitors are recommended for those with eGFR ≥20 mL/min/1.73 m² and type 2 diabetes 2, 1
- GLP-1 receptor agonists are suggested for cardiovascular risk reduction in patients with diabetic CKD 2, 1
- Metformin can be used in patients with eGFR ≥45 mL/min/1.73 m² 2
Antiplatelet Therapy
- Low-dose aspirin is recommended for secondary prevention in people with CKD and established ischemic cardiovascular disease 2
- Aspirin is not recommended for primary prevention in CKD patients 2
Lifestyle Modifications
- Advise patients to adopt diets with higher consumption of plant-based foods compared to animal-based foods 1
- Suggest maintaining a protein intake of 0.8 g/kg body weight/day 1
- Avoid high protein intake (>1.3 g/kg/day) in adults with CKD at risk of progression 1
- Encourage moderate-intensity physical activity for at least 150 minutes per week 1
- Sodium restriction (2.3 g/d) is critical to optimize the effectiveness of antihypertensive medications 2
Monitoring and Follow-up
- Monitor for complications of CKD such as hyperkalemia, metabolic acidosis, hyperphosphatemia, vitamin D deficiency, secondary hyperparathyroidism, and anemia 1
- Regular risk factor reassessment every 3-6 months 1
- Monitor blood pressure, weight, serum electrolytes, hemoglobin, calcium, phosphate, PTH, and vitamin D levels 2
Common Pitfalls and Caveats
- Avoid simultaneous use of ACE inhibitors and ARBs as this combination increases risk of hyperkalemia and acute kidney injury without providing additional benefits 2
- Be cautious with diuretics in CKD patients as they may cause electrolyte imbalances and worsen kidney function if overused 3
- Monitor for orthostatic hypotension when initiating or increasing doses of antihypertensive medications 2
- Recognize that blood pressure targets may need to be individualized in elderly or frail patients to avoid adverse events 2
- Be vigilant about medication dosing adjustments as kidney function changes over time 4