What is the management for a Chronic Kidney Disease (CKD) patient with a Glomerular Filtration Rate (GFR) between 30-60?

Management of CKD Patients with GFR 30-60 mL/min/1.73 m²

For CKD patients with GFR 30-60 mL/min/1.73 m² (Stage 3), implement SGLT2 inhibitors and RAS blockade based on albuminuria status, initiate statin therapy for cardiovascular protection, target blood pressure <130/80 mmHg, and monitor for complications with increasing frequency as GFR declines. 1

Confirm CKD Stage and Risk Stratification

• Measure urinary albumin-to-creatinine ratio (UACR) immediately on a random spot urine sample, as albuminuria classification is essential for determining treatment intensity and prognosis 1, 2
• Verify that kidney dysfunction has persisted >3 months by reviewing historical eGFR measurements to confirm CKD rather than acute kidney injury 2
• Risk stratification depends on both GFR and albuminuria: patients with GFR 30-44 (G3b) plus UACR >300 mg/g represent very high risk requiring nephrology referral and quarterly monitoring 2

Pharmacologic Kidney Protection

RAS Inhibition (ACE Inhibitors or ARBs)

• Start ACE inhibitor or ARB for patients with moderately-to-severely increased albuminuria (UACR ≥30 mg/g), regardless of diabetes status 1
• For diabetes with UACR ≥30 mg/g: ACE inhibitor or ARB is strongly recommended (Grade 1B) 1
• For non-diabetes with UACR ≥300 mg/g: ACE inhibitor or ARB is strongly recommended (Grade 1B) 1
• For non-diabetes with UACR 30-299 mg/g: ACE inhibitor or ARB is suggested (Grade 2C) 1
• Continue ACE inhibitor or ARB even when eGFR falls below 30 mL/min/1.73 m² unless specific contraindications develop 1
• Use the highest approved tolerated dose to achieve maximum benefit, as proven benefits were achieved in trials using these doses 1
• Check blood pressure, serum creatinine, and potassium within 2-4 weeks of initiation or dose increase 1
• Continue therapy unless creatinine rises >30% within 4 weeks of initiation 1
• Never combine ACE inhibitor + ARB + direct renin inhibitor, as this increases adverse events without benefit (Grade 1B) 1, 3

SGLT2 Inhibitors

• For type 2 diabetes with eGFR ≥20 mL/min/1.73 m²: initiate SGLT2 inhibitor (Grade 1A) 1
• For eGFR 30-60 with UACR ≥200 mg/g: initiate SGLT2 inhibitor regardless of diabetes status (Grade 1A) 1
• For eGFR 30-44 with UACR <200 mg/g: SGLT2 inhibitor is suggested (Grade 2B) 1
• Once initiated, continue SGLT2 inhibitor even if eGFR falls below 20 mL/min/1.73 m² unless not tolerated or dialysis starts 1
• Withhold during prolonged fasting, surgery, or critical illness due to ketosis risk 1
• The reversible eGFR decrease on initiation is not an indication to discontinue 1

Nonsteroidal Mineralocorticoid Receptor Antagonists

• For type 2 diabetes with eGFR >25 mL/min/1.73 m² and persistent albuminuria (>30 mg/g) despite maximum tolerated RAS inhibitor: consider nonsteroidal MRA (Grade 2A) 1
• Most appropriate for patients at high risk of progression with persistent albuminuria despite standard therapies 1
• May be added to RAS inhibitor + SGLT2 inhibitor combination 1
• Select patients with consistently normal potassium to mitigate hyperkalemia risk 1

Cardiovascular Risk Reduction

Lipid Management

• For age ≥50 years with eGFR 30-60: initiate statin or statin/ezetimibe combination (Grade 1A) 1
• Choose statin-based regimens to maximize absolute LDL cholesterol reduction 1
• For age 18-49 years: initiate statin if coronary disease, diabetes, prior stroke, or 10-year cardiovascular risk >10% (Grade 2A) 1
• Consider PCSK-9 inhibitors for patients with indication 1

Antiplatelet Therapy

• Aspirin is NOT recommended for primary prevention in CKD patients 1
• For secondary prevention with established cardiovascular disease: use low-dose aspirin (Grade 1C) 1
• Consider P2Y12 inhibitors if aspirin intolerance 1

Blood Pressure Management

• Target blood pressure <130/80 mmHg for all CKD patients 1
• Use ACE inhibitor or ARB as first-line agent, particularly with albuminuria 1
• Monitor blood pressure within 2-4 weeks of RAS inhibitor initiation or dose adjustment 1

Diabetes Management (if applicable)

• For eGFR 30-60: metformin requires dose adjustment or discontinuation 1, 4
• Metformin is contraindicated if eGFR <30 mL/min/1.73 m² and must be discontinued immediately 1, 4
• Do not initiate metformin if eGFR 30-45 mL/min/1.73 m² 4
• If already on metformin and eGFR falls to 30-45: reduce dose to 50% and assess benefit-risk 4
• DPP-4 inhibitors require dose adjustment: sitagliptin 50 mg daily if eGFR 30-50, saxagliptin 2.5 mg daily if eGFR ≤45, alogliptin 12.5 mg daily if eGFR 30-60 1
• Target HbA1c <7% for most patients, measured twice yearly or quarterly if not at target 1

Monitoring for CKD Complications

Electrolyte Management

• Monitor potassium, sodium, bicarbonate at baseline and regularly 1
• Check potassium within 2-4 weeks after initiating or increasing RAS inhibitor dose 1
• Hyperkalemia with RAS inhibitor can often be managed with potassium-lowering measures rather than stopping the drug 1
• Limit intake of foods rich in bioavailable potassium (processed foods) for patients with hyperkalemia history 1

Mineral Bone Disease

• Measure parathyroid hormone (PTH) as it begins rising when eGFR <60 mL/min/1.73 m² 1
• Check serum calcium, phosphate, and 25-hydroxyvitamin D 1

Anemia Screening

• Monitor hemoglobin regularly as anemia commonly develops in Stage 3 CKD 1

Metabolic Acidosis

• Evaluate serum bicarbonate, as metabolic acidosis commonly develops at this level of kidney function 5

Dietary Modifications

• Limit dietary protein to maximum 0.8 g/kg/day (the recommended daily allowance) for non-dialysis CKD Stage 3 or higher (Grade A) 1
• Consider plant-based "Mediterranean-style" diet for cardiovascular risk reduction 1
• Limit alcohol, meats, and high-fructose corn syrup to prevent gout 1

Monitoring Frequency

• For GFR 45-59 (G3a) with UACR <30 mg/g: monitor eGFR and UACR annually 2
• For GFR 45-59 with UACR 30-300 mg/g: monitor twice yearly 2
• For GFR 30-44 (G3b) with UACR <30 mg/g: monitor twice yearly 2
• For GFR 30-44 with UACR 30-300 mg/g: monitor 3 times yearly 2
• For GFR 30-44 with UACR >300 mg/g: monitor quarterly and refer to nephrology 2

Nephrology Referral Indications

• Refer immediately if eGFR <30 mL/min/1.73 m² (approaching Stage 4) 1, 2, 5
• Refer for uncertainty about kidney disease etiology or atypical features 1, 2
• Refer for continuously increasing albuminuria despite optimal management 2
• Refer for rapidly progressing kidney disease (eGFR decline >5 mL/min/year) 1
• Refer for difficult management issues including resistant hypertension or uncontrolled hyperkalemia 1, 2

Critical Pitfalls to Avoid

• Do not discontinue RAS inhibitor for creatinine increases ≤30% in absence of volume depletion 1
• Do not combine ACE inhibitor with ARB, as dual RAS blockade increases hyperkalemia and acute kidney injury without additional benefit 1, 3
• Do not use aspirin for primary prevention in CKD, as recent trials show no benefit and increased bleeding risk 1
• Do not continue metformin if eGFR falls below 30 mL/min/1.73 m² due to lactic acidosis risk 1, 4
• Do not skip albuminuria testing, as eGFR and UACR provide independent prognostic information 2
• Do not delay nephrology referral until eGFR <15, as earlier referral (at eGFR <30) reduces costs, improves outcomes, and allows preparation for renal replacement therapy 5