What is the medical management for an elderly male patient with Chronic Kidney Disease (CKD) stage 3?

Medical Management of CKD Stage 3 in an Elderly Male

For an elderly male with CKD stage 3, implement comprehensive medical management focusing on blood pressure control with ACE inhibitors or ARBs (targeting ≤140/90 mmHg, or ≤130/80 mmHg if albuminuria present), initiate statin therapy for cardiovascular protection, avoid all nephrotoxic medications especially NSAIDs, adjust medication doses for renal function, and monitor kidney function every 3-5 months. 1

Blood Pressure Management

• Target blood pressure ≤140/90 mmHg for patients without significant albuminuria (<30 mg/24 hours) 1
• Target more intensive control at ≤130/80 mmHg if albuminuria ≥30 mg/24 hours is present 1
• Use ACE inhibitors or ARBs as first-line antihypertensive therapy, particularly when albuminuria is documented 1
• Add dihydropyridine calcium channel blockers and/or diuretics if needed to achieve blood pressure targets 1
• Do not discontinue renin-angiotensin system blockade for serum creatinine increases ≤30% in the absence of volume depletion 1

Cardiovascular Risk Reduction

• Initiate statin therapy immediately as this patient is over 50 years with eGFR <60 ml/min/1.73 m² (strong recommendation) 1
• Consider rosuvastatin 5 mg daily, maximum 10 mg daily for CKD stage 3B 2
• Maximize absolute reduction in LDL cholesterol with statin regimens 1
• Consider adding ezetimibe or PCSK9 inhibitors based on ASCVD risk and lipid levels 1
• Prescribe low-dose aspirin if established cardiovascular disease is present 1
• Consider SGLT2 inhibitors if the patient has type 2 diabetes, as they reduce CKD progression and cardiovascular events 1
• Consider nonsteroidal mineralocorticoid receptor antagonists in patients with diabetes 1

Medication Management and Dose Adjustments

• Estimate creatinine clearance and adjust doses of all renally cleared medications according to pharmacokinetic data 3, 1
• Completely avoid NSAIDs in CKD stage 3 due to nephrotoxicity risk and potential for acute kidney injury 2, 1
• Review and limit use of over-the-counter medicines and dietary/herbal remedies that may be harmful 1
• Perform thorough medication review periodically and at transitions of care to assess adherence, continued indications, and potential drug interactions 1
• Weight-based dosing where appropriate for anticoagulant and antiplatelet therapy to decrease bleeding risk 3

Monitoring and Laboratory Surveillance

• Monitor eGFR, electrolytes, and therapeutic medication levels regularly, approximately every 3-5 months for stage 3 CKD 1
• Assess urinary albumin excretion to further stratify risk and guide therapy 1
• Screen for complications including hypertension, volume overload, electrolyte abnormalities, metabolic acidosis, anemia, and metabolic bone disease 1
• Evaluate transferrin saturation and serum ferritin prior to and during treatment 4
• Administer supplemental iron therapy when serum ferritin is <100 mcg/L or when serum transferrin saturation is <20% 4
• Administer adequate hydration to patients undergoing coronary and LV angiography 3

Dietary Recommendations

• Restrict dietary protein intake to 0.8 g/kg body weight per day (the recommended daily allowance) 1
• Restrict dietary sodium to <2,300 mg/day to control blood pressure and reduce cardiovascular risk 1
• Consider a plant-based Mediterranean-style diet to further reduce cardiovascular risk 2, 1
• Limit alcohol, meats, and high-fructose corn syrup intake as these may contribute to inflammatory conditions 2
• Individualized dietary counseling through a renal dietitian is advisable for CKD stage 3 2

Management of CKD Complications

• Screen for and manage anemia, metabolic acidosis, and metabolic bone disease as these become more prevalent in stage 3 CKD 1
• For inflammatory conditions (such as gout), use low-dose colchicine or glucocorticoids rather than NSAIDs 2, 1
• Patients may require adjustments in their dialysis prescriptions after initiation of erythropoietin-stimulating agents if on dialysis 4
• Patients receiving erythropoietin may require increased anticoagulation with heparin to prevent clotting of the extracorporeal circuit during hemodialysis 4

Nephrology Referral Considerations

• Consider nephrology referral for patients with eGFR <45 ml/min/1.73 m² (CKD stage 3B) 1
• Immediate referral is warranted for uncertainty about etiology, difficult management issues, or rapidly progressing kidney disease 1
• All patients with CKD stages 4-5 should be referred to nephrology 5
• Establish a protocol for joint follow-up between primary care and nephrology 5

Special Considerations for Elderly Patients

• Individualize pharmacotherapy with dose adjusted by weight and/or creatinine clearance to reduce adverse events caused by age-related changes in pharmacokinetics/dynamics, volume of distribution, comorbidity, drug interactions, and increased drug sensitivity 3
• Undertake patient-centered management considering patient preferences/goals, comorbidities, functional and cognitive status, and life expectancy 3
• Older patients were less likely to achieve systolic targets and more likely to achieve diastolic targets in CKD management 6
• Multimorbidity presents a major challenge for CKD self-management in older adults, requiring an integrated treatment approach 7

Critical Pitfalls to Avoid

• Never prescribe NSAIDs in CKD stage 3, even for short-term use, as this significantly increases risk of acute kidney injury and CKD progression 2, 1
• Do not overlook statin therapy as cardiovascular disease is the leading cause of mortality in CKD patients 2
• Avoid inadequate hydration before contrast procedures 3
• Do not use routine blood transfusion in hemodynamically stable patients with hemoglobin levels >8 g/dL 3
• Suboptimal blood pressure control is particularly common in CKD patients with diabetes and/or albuminuria, who require more aggressive management 6