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

Management of CKD Stage 3b

The management of CKD stage 3b requires a comprehensive treatment strategy targeting blood pressure control, cardiovascular risk reduction, lifestyle modifications, and monitoring for complications to reduce disease progression and associated morbidity and mortality. 1, 2

Risk Assessment and Monitoring

• Monitor eGFR, electrolytes, and therapeutic medication levels regularly, approximately every 3-5 months for stage G3b CKD 1
• Assess urinary albumin excretion to further stratify risk and guide therapy 1
• Use validated risk prediction tools with a 2-year kidney failure risk threshold of >10% determining timing for multidisciplinary care 3
• Perform thorough medication review periodically to assess adherence, continued indications, and potential drug interactions 1
• Screen for complications including hypertension, volume overload, electrolyte abnormalities, metabolic acidosis, anemia, and metabolic bone disease 1

Blood Pressure Management

• Target blood pressure ≤140/90 mmHg for patients with urine albumin excretion <30 mg/24 hours 1
• Aim for more intensive control with target ≤130/80 mmHg for patients with albuminuria ≥30 mg/24 hours 1, 4
• Use ACE inhibitors or ARBs as first-line therapy, especially if albuminuria is present 1, 5
• Titrate ACEi or ARBs to the highest approved dose that is tolerated to maximize kidney protection 3
• Add dihydropyridine calcium channel blockers and/or diuretics if needed to achieve BP targets 6
• Do not discontinue renin-angiotensin system blockade for increases in serum creatinine (≤30%) in the absence of volume depletion 1

Cardiovascular Risk Reduction

• Initiate statin therapy for patients over 50 years with eGFR <60 ml/min/1.73 m² (strong recommendation) 1, 2
• Choose statin regimens that maximize absolute reduction in LDL cholesterol 2
• Consider adding ezetimibe or PCSK9 inhibitors based on ASCVD risk and lipid levels 6
• Prescribe low-dose aspirin if the patient has established cardiovascular disease 1
• Consider SGLT2 inhibitors, especially if the patient has type 2 diabetes, as they reduce CKD progression and cardiovascular events 1, 5, 7
• Consider nonsteroidal mineralocorticoid receptor antagonists in people with diabetes 6

Medication Management

• Adjust medication dosages according to kidney function 3
• Avoid nephrotoxic medications including NSAIDs 1
• Review and limit use of over-the-counter medicines and dietary/herbal remedies that may be harmful 1
• For patients with atrial fibrillation, prefer non-vitamin K antagonist oral anticoagulants (NOACs) over vitamin K antagonists, with appropriate dose adjustments based on GFR 3

Dietary Recommendations

• Maintain dietary protein intake of 0.8 g/kg body weight per day (the recommended daily allowance) 1, 3
• Restrict dietary sodium to <2,300 mg/day to control blood pressure and reduce cardiovascular risk 1, 2
• Consider a plant-based "Mediterranean-style" diet to further reduce cardiovascular risk 1, 3
• Avoid high protein intake (>1.3 g/kg body weight/day) in adults with CKD at risk of progression 3
• Limit foods with high potassium content in patients with history of hyperkalemia 3

Lifestyle Modifications

• Recommend moderate-intensity physical activity for at least 150 minutes per week, adjusted to cardiovascular and physical tolerance 3, 2
• Advise patients to avoid sedentary behavior 3, 2
• Encourage weight loss for patients with obesity and CKD 3, 2
• Promote smoking cessation 3, 2

Management of Complications

• Screen for and manage anemia, metabolic acidosis, and metabolic bone disease 1
• Treat symptomatic hyperuricemia (gout) with urate-lowering therapy, preferring xanthine oxidase inhibitors over uricosuric agents 3
• Consider low-dose colchicine or glucocorticoids rather than NSAIDs for acute gout management 1
• Provide pharmacological treatment with or without dietary intervention to prevent acidosis (serum bicarbonate <18 mmol/L) 3
• Monitor treatment to ensure serum bicarbonate doesn't exceed normal limits and doesn't negatively impact blood pressure, serum potassium, or fluid balance 3

Referral to Specialist Care

• Consider nephrology referral for patients with eGFR <45 ml/min/1.73 m² 1
• Immediate referral is warranted for uncertainty about etiology, difficult management issues, or rapidly progressing kidney disease 1
• Refer adults with CKD to specialist kidney care services when they have ACR ≥30 mg/g (3 mg/mmol) or PCR ≥200 mg/g (20 mg/mmol) 2
• Refer adults with CKD to specialist kidney care services when they have persistent hematuria 2

Patient Education

• Educate the patient regarding expected benefits and possible risks of medications 1
• Emphasize the importance of medication adherence and regular monitoring 1
• Advise on following radiology society guidelines for contrast administration if imaging studies with contrast are required 1