Treatment of Stage 3 Chronic Kidney Disease
For stage 3 CKD, initiate an ACE inhibitor or ARB if the patient has hypertension, and start statin therapy for elevated LDL cholesterol—these are the two cornerstone pharmacologic interventions proven to reduce cardiovascular mortality and slow disease progression. 1
Core Pharmacologic Management
Blood Pressure Control with RAS Inhibition
- Use either an ACE inhibitor or an angiotensin II receptor blocker (ARB) as first-line antihypertensive therapy in all stage 3 CKD patients with hypertension 1
- ARBs carry high-quality evidence for this indication, while ACE inhibitors have moderate-quality evidence 1
- These agents reduce proteinuria more effectively than other antihypertensives and slow progression to end-stage renal disease 2
- Target blood pressure should be <140/90 mmHg in patients without albuminuria and <130/80 mmHg in those with albuminuria 3
Lipid Management
- Initiate statin therapy for elevated LDL cholesterol in all stage 3 CKD patients (strong recommendation, moderate-quality evidence) 1
- This reduces cardiovascular mortality, which is the leading cause of death in CKD patients—most patients with progressive CKD die from cardiovascular disease before reaching kidney failure 1, 4
Secondary Prevention Strategies
Disease Progression Monitoring
- Evaluate and treat the underlying cause of kidney disease 1
- Monitor renal function periodically, particularly in patients on RAS inhibitors 5
- Consider withholding or discontinuing RAS inhibitors if clinically significant renal function decline occurs 5
- Monitor serum potassium regularly, as RAS inhibitors increase hyperkalemia risk 5
Lifestyle Modifications
- Implement dietary sodium restriction to optimize blood pressure control and reduce volume overload 3, 6
- Recommend low-protein diet (approximately 1 g/kg/day) to slow CKD progression 3, 7
- Encourage regular walking and weight loss, which slow CKD progression 3
- Adherence to Mediterranean diet patterns delays disease advancement 3
- Eliminate smoking and avoid binge alcohol drinking, both of which accelerate CKD progression 3
Management of Complications
Diabetes Control (if applicable)
- Maintain hemoglobin A1c <8% if achievable without frequent hypoglycemia 7
- Consider SGLT2 inhibitors, which substantially reduce cardiovascular complications and slow CKD progression in patients already on RAS inhibitors 4
- Insulin is the preferred treatment for patients requiring medication as renal function declines 6
Cardiovascular Risk Reduction
- Address all cardiovascular risk factors aggressively, as cardiovascular disease is the primary cause of death in stage 3 CKD 1, 4
- Treat hypertension, hyperlipidemia, and diabetes as part of comprehensive cardiovascular risk management 5
Nephrology Referral Considerations
When to Refer
- Refer to nephrology when GFR falls below 30 mL/min/1.73 m² (approaching stage 4), though stable patients with clear diagnoses may not require formal referral 1
- Earlier referral is warranted for: persistent proteinuria >1 g/day, rapidly declining GFR (>20% decrease), refractory hypertension requiring ≥4 agents, recurrent nephrolithiasis, or hereditary kidney disease 1
- Most stage 3 CKD patients do not progress to end-stage renal disease but die from cardiovascular causes, making primary care cardiovascular risk reduction critically important 1
Critical Monitoring Parameters
Avoid Common Pitfalls
- Preserve peripheral veins in stage 3 CKD patients—avoid unnecessary venipuncture in anticipation of potential future dialysis access needs 6
- Correct volume or salt depletion before initiating RAS inhibitors to prevent symptomatic hypotension 5
- Be aware that RAS inhibitors may cause acute renal failure in patients with renal artery stenosis, severe heart failure, or volume depletion 5
- Do not routinely test for proteinuria in patients already taking ACE inhibitors or ARBs, as this does not change management 1
Vaccination
- Ensure vaccination against influenza, tetanus, hepatitis B, pneumococcus, and HPV (through age 26) 6