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

Management of CKD Stage 3T (Transplant)

For kidney transplant recipients with CKD stage 3T, monitor serum calcium and phosphorus every 6-12 months, PTH once with subsequent intervals based on baseline level and CKD progression, and measure alkaline phosphatase annually or more frequently if PTH is elevated. 1

Mineral and Bone Disorder Monitoring

The KDIGO guidelines provide specific monitoring intervals for transplant patients that differ from non-transplant CKD:

• Serum calcium and phosphorus: Every 6-12 months 1
• PTH: Measure once initially, then adjust frequency based on baseline level and rate of CKD progression 1
• Alkaline phosphatase: Annually, or more frequently if PTH is elevated 1
• 25(OH)D (calcidiol): Should be measured, with repeat testing determined by baseline values and interventions 1

If biochemical abnormalities are identified or treatments for CKD-MBD are initiated, increase monitoring frequency to assess for efficacy and side effects. 1

Vitamin D Management

Correct vitamin D deficiency and insufficiency using treatment strategies recommended for the general population. 1

This approach applies to all CKD stages in transplant recipients (stages 1-5T). 1

Bone Mineral Density Assessment

For transplant recipients with eGFR >30 mL/min/1.73 m² (which includes stage 3T):

• Measure BMD in the first 3 months post-transplant if receiving corticosteroids or have risk factors for osteoporosis 1
• Consider treatment with vitamin D, calcitriol/alfacalcidiol, or bisphosphonates in the first 12 months if low BMD is present 1
• Insufficient data exist to guide treatment after the first 12 months 1

Important caveat: Do not routinely perform BMD testing in CKD stages 4-5T, as BMD does not predict fracture risk or type of transplant bone disease in advanced CKD. 1

Hematologic Monitoring

Perform complete blood counts monthly for months 4-12 post-transplant, then at least annually thereafter, and after any medication change that may cause neutropenia, anemia, or thrombocytopenia. 1

Assess and treat anemia by removing underlying causes whenever possible and using standard measures applicable to CKD. 1

Cancer Screening

Screen for cancers according to local guidelines for the general population:

• Women: Cervical, breast, and colon cancer 1
• Men: Prostate and colon cancer 1

For patients with compensated cirrhosis, obtain hepatic ultrasound and alpha-fetoprotein every 12 months. 1

Key Differences from Non-Transplant CKD Stage 3

The "T" designation is critical because transplant recipients require:

• Less frequent mineral metabolism monitoring compared to non-transplant CKD stage 3 (every 6-12 months vs. more frequent in native kidney disease) 1
• Different bone disease management due to unique pathophysiology of transplant bone disease 1
• Ongoing immunosuppression management considerations that affect all other treatments 1
• Enhanced cancer surveillance due to immunosuppression-related malignancy risk 1