Management of Stage 3A CKD in a 69-Year-Old Female
For a 69-year-old female with GFR 39 mL/min/1.73 m² and creatinine 1.49 mg/dL (Stage 3A CKD), the primary medication focus should be on ACE inhibitors or ARBs if she has hypertension, diabetes, or albuminuria, with careful dose adjustment and monitoring for hyperkalemia and acute kidney injury. 1
Renoprotective Medications
ACE Inhibitors or ARBs (First-Line for Kidney Protection)
ACE inhibitors (such as lisinopril) or ARBs are strongly recommended if this patient has albuminuria (urine albumin-to-creatinine ratio ≥30 mg/g), coronary artery disease, diabetes, or hypertension to reduce progressive kidney disease risk 1
For lisinopril specifically at this GFR level (39 mL/min/1.73 m²), no dose adjustment is required since her creatinine clearance is >30 mL/min—the standard starting dose of 5-10 mg daily for hypertension can be used 2
Monitor serum creatinine and potassium within 7-14 days after initiation and at least annually, as ACE inhibitors/ARBs can cause hyperkalemia and transient creatinine elevation 1
Continuation of ACE inhibitors/ARBs as kidney function declines to eGFR <30 mL/min/1.73 m² may provide cardiovascular benefit without significantly increasing end-stage kidney disease risk 1
A creatinine increase up to 20% after starting therapy is acceptable and should not be interpreted as progressive renal deterioration 1
Antihypertensive Therapy (If Hypertension Present)
Initial treatment options include: ACE inhibitors, ARBs, thiazide-like diuretics (chlorthalidone or indapamide preferred), or dihydropyridine calcium channel blockers 1
In the absence of albuminuria, ACE inhibitors and ARBs have not shown superior cardioprotection compared to thiazide-like diuretics or calcium channel blockers 1
Multiple-drug therapy is often required to achieve blood pressure targets, particularly with diabetic kidney disease 1
Never combine ACE inhibitors with ARBs or direct renin inhibitors, as this increases adverse events including hyperkalemia, syncope, and acute kidney injury without added cardiovascular benefit 1
Medications Requiring Dose Adjustment or Avoidance
Metformin Management
Metformin should be reviewed at GFR 30-44 mL/min/1.73 m² (Stage 3B) but can be continued at GFR ≥45 mL/min/1.73 m² 1
At her current GFR of 39 mL/min/1.73 m², metformin use requires careful review and consideration of dose reduction, though it is not absolutely contraindicated 1
Medications to Temporarily Discontinue During Acute Illness
- During serious intercurrent illness that increases AKI risk, temporarily discontinue: RAAS blockers (ACE inhibitors, ARBs, aldosterone inhibitors), diuretics, NSAIDs, metformin, lithium, and digoxin 1
General Drug Dosing Principles
Drug dosing should be based on GFR level for medications excreted by the kidneys to avoid life-threatening complications 1
For drugs with narrow therapeutic ranges, methods based on cystatin C or direct GFR measurement may be needed when estimates are unreliable (e.g., due to low muscle mass) 1
Avoid herbal remedies entirely in patients with CKD 1
Seek medical or pharmacist advice before using over-the-counter medicines or nutritional protein supplements 1
Monitoring Considerations
Accurate GFR Assessment
The Cockcroft-Gault formula tends to overestimate creatinine clearance in CKD Stage 3-5, while the MDRD formula is more reliable across the full range of renal function 1
In elderly women specifically, renal function declines approximately 16.6 mL/min/1.73 m² per decade, with acceleration after age 80 3
Serum creatinine may remain within normal limits despite reduced renal function in elderly patients due to decreased muscle mass, exercise, and meat intake 1
Regular Monitoring Requirements
Monitor GFR, electrolytes, and drug levels regularly for patients taking potentially nephrotoxic agents like lithium and calcineurin inhibitors 1
Assess for albuminuria using spot urine albumin-to-creatinine ratio, as microalbuminuria predicts cardiovascular events and progressive kidney disease even in non-diabetic hypertensive patients 1
Common Pitfalls to Avoid
Do not withhold appropriate therapies (including cancer treatments) due to CKD, but ensure appropriate dose adjustments based on GFR 1
Avoid NSAIDs, as they are nephrotoxic and may hasten CKD progression or precipitate acute kidney injury 1
Do not use gadolinium-containing contrast media without careful consideration at GFR <30 mL/min/1.73 m² due to nephrogenic systemic fibrosis risk 1
Ensure adequate hydration with saline before, during, and after iodinated contrast procedures, and measure GFR 48-96 hours post-procedure 1