What are the clinical guidelines for managing a patient with Chronic Kidney Disease (CKD) stage 3, including those with comorbid conditions such as hypertension or diabetes?

Management of CKD Stage 3

For patients with CKD stage 3, initiate an ACE inhibitor or ARB (titrated to maximum tolerated dose) if hypertension and albuminuria are present, target blood pressure to 120-129 mmHg systolic when tolerated, start statin therapy for cardiovascular protection, and implement dietary sodium restriction to <2g/day along with a plant-based diet. 1

Blood Pressure Management

Target Blood Pressure

• Target systolic BP <120 mmHg when tolerated using standardized office measurement for adults with CKD stage 3 and hypertension 1
• For patients with eGFR >30 mL/min/1.73 m², target systolic BP to 120-129 mmHg if tolerated 1
• In older adults (≥65 years), target systolic BP range of 130-139 mmHg 1
• Avoid intensive BP lowering in patients with frailty, high fall risk, limited life expectancy, or symptomatic postural hypotension 1

First-Line Antihypertensive Therapy

• Initiate ACE inhibitor or ARB in patients with diabetes, hypertension, AND albuminuria (>30 mg/g) 1
• Titrate to the highest approved dose that is tolerated 1
• Monitor serum potassium and creatinine within 2-4 weeks of initiation or dose changes 1
• Continue therapy even if creatinine increases up to 30% from baseline 1
• Never combine ACE inhibitors with ARBs - this combination is harmful and should be avoided 1

Important Caveats for RAS Blockade

• For patients with diabetes, albuminuria, but normal BP, RAS blockade may still be considered given the strong association between albuminuria and disease progression 1
• For patients with diabetes, hypertension, but normal albumin excretion, RAS inhibitors have not proven kidney protective effects - other antihypertensives are equally effective 1
• If cough develops with ACE inhibitors, switch to ARB 1
• For hyperkalemia during titration, implement potassium restriction, add diuretics, use sodium bicarbonate if metabolic acidosis present, or consider gastrointestinal cation exchangers 1

Cardiovascular Risk Reduction

Lipid Management

• Initiate statin therapy for all patients with CKD stage 3 to manage elevated LDL cholesterol 1
• For patients ≥50 years with CKD stage 3, strongly recommend statin or statin/ezetimibe combination therapy 2
• For patients 18-49 years with CKD stage 3, initiate statin if they have known coronary disease, diabetes, prior ischemic stroke, or estimated 10-year cardiovascular risk >10% 2

Antiplatelet Therapy

• Use aspirin lifelong for secondary prevention in patients with established cardiovascular disease 1
• Consider low-dose aspirin for primary prevention in high-risk individuals, balanced against bleeding risk (particularly with thrombocytopathy at low GFR) 1, 2
• Use dual antiplatelet therapy after acute coronary syndrome or percutaneous coronary intervention per standard guidelines 1

Dietary and Lifestyle Modifications

Protein Intake

• Maintain protein intake of 0.8 g/kg body weight/day in adults with CKD stage 3 1
• Avoid high protein intake (>1.3 g/kg body weight/day) in adults at risk of progression 1
• Do not prescribe low-protein diets in metabolically unstable patients 1
• In older adults with frailty and sarcopenia, consider higher protein and calorie targets 1

Sodium Restriction

• Limit sodium intake to <2 g/day (or <90 mmol/day, or <5 g sodium chloride/day) 1
• Sodium restriction is not appropriate for patients with sodium-wasting nephropathy 1

Dietary Pattern

• Adopt a plant-based Mediterranean-style diet with higher consumption of plant-based foods compared to animal-based foods 1, 2
• Reduce consumption of ultraprocessed foods 1
• Limit alcohol, meats, and high-fructose corn syrup intake 2
• Use low-fat or nonfat dairy products 1

Physical Activity

• Undertake moderate-intensity physical activity for at least 150 minutes per week, or to a level compatible with cardiovascular and physical tolerance 1
• Avoid sedentary behavior 1
• For patients at higher risk of falls, provide specific advice on intensity (low, moderate, or vigorous) and type of exercises (aerobic vs. resistance) 1
• Encourage weight loss in patients with obesity and CKD 1

Tobacco Cessation

• Advise all patients with CKD who use tobacco to quit using tobacco products 1
• Refer to smoking cessation programs where available 1

Diabetes Management (if applicable)

Glycemic Control

• Comprehensive diabetes care includes regular screening for retinopathy, neuropathy, and foot complications 1
• Glycemic control requires careful monitoring due to increased hypoglycemia risk in CKD 2
• Metformin should be used with caution or avoided if serum creatinine ≥1.5 mg/dL in men or ≥1.4 mg/dL in women 2

SGLT2 Inhibitors

• SGLT2 inhibitors are recommended for patients with type 2 diabetes and CKD when eGFR ≥30 mL/min/1.73 m² 1
• These agents reduce risks of CKD progression and cardiovascular events 1

Medication Safety and Monitoring

Medication Review

• Review all medications for appropriate dosing in CKD stage 3 2
• Avoid nephrotoxic medications, particularly NSAIDs 2
• Adjust doses of renally cleared medications based on eGFR 2

Monitoring Parameters

• Monitor blood pressure regularly, preferably with 24-hour ambulatory devices for accurate assessment 2
• Check serum potassium and creatinine within 2-4 weeks of initiating or changing RAS blockade 1
• Monitor for postural hypotension when treating with BP-lowering medications 2

Multidisciplinary Care and Referrals

Specialist Involvement

• Refer to renal dietitians or accredited nutrition providers for individualized dietary education regarding sodium, phosphorus, potassium, and protein intake 1
• Consider referral to nephrology for rapid decline in GFR, significant albuminuria (>300 mg/day), refractory hypertension, persistent electrolyte abnormalities, recurrent nephrolithiasis, or hereditary kidney disease 2
• Utilize psychologists, pharmacists, physical and occupational therapy, and smoking cessation programs where indicated 1

Key Clinical Context

• Most patients with CKD stage 3 die from cardiovascular causes rather than progressing to end-stage renal disease, making cardiovascular risk reduction paramount 2
• A recorded CKD diagnosis is associated with improved management practices, increased prescribing of guideline-recommended medications, and attenuated eGFR decline 3
• Delayed diagnosis is associated with elevated risk of progression to stage 4/5, kidney failure, and composite cardiovascular events 3