What is the management for an elderly woman with Chronic Kidney Disease (CKD) stage 3, Diabetes Mellitus (DM), and Hypertension (HTN)?

Management of CKD Stage 3 + Diabetes Mellitus + Hypertension in an Elderly Woman

For an elderly woman with CKD stage 3, diabetes, and hypertension, initiate SGLT2 inhibitors and metformin for glycemic control, target blood pressure <130/80 mmHg with RAS blockade (ACE inhibitor or ARB) as first-line therapy, and start moderate-intensity statin therapy—this comprehensive approach reduces cardiovascular mortality, slows kidney disease progression, and improves quality of life. 1

Glycemic Management: First-Line Therapy

Start with the combination of metformin and an SGLT2 inhibitor as foundational therapy for type 2 diabetes with CKD stage 3. 1

• Metformin should be initiated at eGFR ≥30 ml/min/1.73 m² and continued as tolerated, with dose adjustment based on kidney function. 1
• SGLT2 inhibitors (empagliflozin, dapagliflozin, or canagliflozin) should be started when eGFR is ≥20 ml/min/1.73 m² and continued until dialysis or transplantation, as these agents provide both kidney and cardiovascular protection independent of glucose-lowering effects. 1
• If glycemic targets are not met with metformin and SGLT2 inhibitors, add a GLP-1 receptor agonist as the preferred third agent, which provides additional cardiovascular benefits and weight reduction. 1

Target HbA1c of 7-8% is appropriate for elderly patients, balancing microvascular risk reduction against hypoglycemia risk and shorter life expectancy. 1, 2

Blood Pressure Management: Targeting Cardiovascular Protection

Target blood pressure <130/80 mmHg if tolerated, as this reduces cardiovascular events and mortality in elderly patients with CKD. 1, 3

First-Line Antihypertensive Therapy

• Initiate an ACE inhibitor or ARB as first-line therapy, particularly if albuminuria is present (which is common with diabetes and CKD). 1, 3
• RAS blockade slows progression of diabetic kidney disease and reduces cardiovascular events. 1
• Monitor serum creatinine and potassium within 1-2 weeks of initiating or increasing the dose of ACE inhibitor/ARB. 1, 3, 4
• Continue therapy unless creatinine rises >30% within 4 weeks of initiation. 3

Additional Antihypertensive Agents

• Add a diuretic (thiazide or loop) as second-line therapy to achieve blood pressure targets. 1, 3
• Monitor electrolytes within 1-2 weeks of initiating diuretic therapy and at least yearly. 1
• Dihydropyridine calcium channel blockers can be added as third-line therapy if needed to reach target. 1

Critical Contraindications

Never combine ACE inhibitor + ARB, as this increases adverse effects (hyperkalemia, acute kidney injury) without additional cardiovascular or kidney benefits. 1, 3, 4

• The VA NEPHRON-D trial demonstrated that combining losartan with lisinopril increased hyperkalemia and acute kidney injury without improving outcomes. 4
• Similarly, avoid combining ACE inhibitor or ARB with direct renin inhibitors (aliskiren). 4

Lipid Management: Universal Statin Therapy

Initiate moderate-intensity statin therapy for all elderly patients with diabetes and CKD stage 3, regardless of baseline LDL cholesterol levels. 1

• Statin therapy reduces cardiovascular events and mortality in this high-risk population. 1
• Atorvastatin 10-20 mg daily or rosuvastatin 5-10 mg daily represents appropriate moderate-intensity dosing. 1
• Consider high-intensity statin if the patient has established atherosclerotic cardiovascular disease. 1

Additional Risk-Based Therapy

Add a nonsteroidal mineralocorticoid receptor antagonist (finerenone) if albuminuria persists ≥30 mg/g (≥3 mg/mmol) despite optimal therapy with SGLT2 inhibitor and RAS blockade, and if serum potassium is normal. 1

• Finerenone provides additional kidney and cardiovascular protection in patients with type 2 diabetes, CKD, and persistent albuminuria. 1
• Monitor potassium closely, as the combination of RAS blockade and mineralocorticoid receptor antagonist increases hyperkalemia risk. 1

Lifestyle Modifications: Foundation of Therapy

Implement comprehensive lifestyle interventions as the foundation upon which all pharmacotherapy is built. 1

• Dietary sodium restriction to <2.3 g/day (ideally <2 g/day) improves blood pressure control and reduces cardiovascular risk. 5, 6
• Mediterranean diet or DASH diet patterns reduce blood pressure and slow CKD progression. 5, 6
• Moderate protein intake (0.8-1.0 g/kg/day) may slow CKD progression, though evidence is mixed. 5, 7
• Physical activity ≥150 minutes per week of moderate aerobic exercise plus resistance training twice weekly improves cardiovascular health and blood pressure control. 1, 6, 7
• Weight management through diet and exercise improves blood pressure control and glycemic control. 5, 6
• Smoking cessation is imperative, as smoking accelerates CKD progression and increases cardiovascular risk. 1, 7
• Limit alcohol consumption to moderate levels or abstain completely. 7

Monitoring Schedule

Reassess risk factors every 3-6 months with comprehensive laboratory evaluation. 1

• HbA1c every 3-6 months to assess glycemic control. 1
• Serum creatinine and eGFR every 3-6 months to monitor kidney function. 1
• Urine albumin-to-creatinine ratio every 3-6 months to assess albuminuria and response to therapy. 1
• Serum potassium every 3-6 months, or more frequently when initiating or adjusting RAS blockade or mineralocorticoid receptor antagonists. 1, 3
• Lipid panel annually to assess statin efficacy. 1
• Blood pressure at every visit, with home blood pressure monitoring encouraged. 1, 3

Special Considerations for Elderly Patients

In elderly patients, blood pressure targets may need individualization based on frailty, orthostatic hypotension risk, and tolerability. 1, 3

• The SPRINT trial demonstrated that even frail elderly patients (≥75 years) with CKD benefited from intensive blood pressure control (SBP <120 mmHg), including those with the slowest gait speed. 1, 3
• However, monitor carefully for orthostatic hypotension, falls, and symptomatic hypotension. 3
• **Avoid diastolic blood pressure <65 mmHg** in patients >80 years old. 1

Glycemic targets should balance microvascular risk reduction against hypoglycemia risk and life expectancy. 1, 2

• For relatively healthy elderly patients with good functional status, target HbA1c ≤7%. 1
• For frail elderly patients with limited life expectancy (<5 years), a less stringent target of HbA1c ≤8% is appropriate. 1

Common Pitfalls to Avoid

• Do not combine ACE inhibitor + ARB, as this increases harm without benefit. 1, 3, 4
• Do not withhold SGLT2 inhibitors based on eGFR alone; these agents should be continued until dialysis initiation. 1
• Do not discontinue metformin prematurely; it can be used safely at eGFR ≥30 ml/min/1.73 m² with appropriate dose adjustment. 1
• Do not overlook statin therapy; all patients with diabetes and CKD require statin therapy regardless of LDL levels. 1
• Do not ignore lifestyle modifications; these form the foundation of therapy and improve outcomes independent of pharmacotherapy. 1, 5, 6, 7
• Do not use sulfonylureas as first-line therapy in elderly patients with CKD due to hypoglycemia risk. 2