How do I manage a patient with stage 3 renal disease (Chronic Kidney Disease, CKD) and impaired renal function?

Management of Stage 3 Chronic Kidney Disease

Initiate ACE inhibitor or ARB therapy immediately if albuminuria ≥30 mg/g, add an SGLT2 inhibitor if diabetic with eGFR ≥20 mL/min/1.73 m², and target blood pressure ≤130/80 mmHg to slow disease progression and reduce cardiovascular mortality. 1, 2, 3

Immediate Assessment and Risk Stratification

Before initiating any therapy, obtain these specific measurements to guide your management strategy:

• Measure urine albumin-to-creatinine ratio to categorize albuminuria (normal <30 mg/g, moderate 30-299 mg/g, severe ≥300 mg/g), as this fundamentally determines treatment intensity 3, 4
• Assess diabetes status since diabetic kidney disease requires SGLT2 inhibitor therapy 2, 3
• Measure blood pressure as hypertension control is the cornerstone of slowing CKD progression 2, 3
• Check baseline potassium and repeat creatinine to establish trajectory and monitor for hyperkalemia risk with RAS inhibitor therapy 3, 5
• Calculate 2-year kidney failure risk using validated prediction equations—if >10%, initiate multidisciplinary care; if >40%, begin kidney replacement therapy preparation 1, 4

First-Line Pharmacologic Therapy

Blood Pressure Management with RAS Inhibition

For patients with albuminuria ≥30 mg/g:

• Start ACE inhibitor (e.g., lisinopril) or ARB (e.g., losartan) as first-line therapy regardless of baseline blood pressure 2, 3
• Target blood pressure ≤130/80 mmHg 2, 3, 4
• For albuminuria ≥300 mg/g, RAS inhibition is strongly recommended to prevent kidney disease progression and reduce cardiovascular events 2, 3

For patients with albuminuria <30 mg/g:

• Target blood pressure ≤140/90 mmHg 2
• ACE inhibitor/ARB can still be used but dihydropyridine calcium channel blocker or diuretic are equally appropriate first-line options 1

Critical monitoring after RAS inhibitor initiation:

• Expect and accept creatinine increases up to 30%—this is normal and does not require discontinuation 3, 5
• Check potassium and creatinine within 1-2 weeks of initiation 5
• Monitor renal function periodically as changes including acute renal failure can occur, particularly in patients with renal artery stenosis, severe heart failure, or volume depletion 6, 5

SGLT2 Inhibitor Therapy for Diabetic Patients

If patient has diabetes:

• Add SGLT2 inhibitor (e.g., empagliflozin, dapagliflozin) when eGFR ≥20 mL/min/1.73 m² 2, 3
• Initiate immediately if albuminuria ≥200 mg/g to reduce CKD progression and cardiovascular events 3
• Continue SGLT2 inhibitor alongside ACE inhibitor/ARB as foundational dual therapy 7
• Do not delay initiation—these provide proven kidney and cardiovascular protection 3, 7

Cardiovascular Risk Reduction

Statin therapy is mandatory:

• Prescribe moderate- or high-intensity statin for all patients ≥50 years with stage 3 CKD regardless of cholesterol levels 1, 4
• For patients 18-49 years, initiate statin if they have coronary disease, diabetes, prior stroke, or 10-year coronary event risk >10% 1, 4
• Stage 3 CKD patients have markedly increased cardiovascular mortality risk compared to the general population 3

Glycemic Control (If Diabetic)

• Target HbA1c approximately 7% to slow CKD progression 2, 4
• Use metformin as first-line when eGFR ≥30 mL/min/1.73 m² 2, 4
• SGLT2 inhibitors provide dual benefit for both glycemic control and kidney protection 2, 3

Dietary and Lifestyle Modifications

Protein restriction:

• Limit dietary protein to maximum 0.8 g/kg body weight/day 1, 2, 3, 4
• Do not restrict protein in patients who are cachexic, sarcopenic, or undernourished 1

Sodium restriction:

• Limit sodium intake to <2 g per day (equivalent to <5 g sodium chloride/day) to improve blood pressure control and reduce proteinuria 2, 3, 4

Physical activity:

• Prescribe moderate-intensity physical activity for cumulative duration of at least 150 minutes per week 1, 4
• Adjust intensity based on cardiovascular tolerance and frailty level 1

Weight management:

• Achieve healthy BMI of 20-25 kg/m² through diet, physical activity, and behavioral therapy 3, 4

Dietary pattern:

• Advise adoption of plant-based diets with higher consumption of plant-based foods compared to animal-based foods and lower consumption of ultraprocessed foods 1, 4

Tobacco cessation:

• Advise complete cessation of tobacco products 1, 3

Medication Safety and Dose Adjustments

Critical medication management:

• Completely avoid NSAIDs as they significantly increase acute kidney injury risk and accelerate CKD progression 3, 8
• Adjust doses of all renally cleared medications based on eGFR 1, 3, 4
• Review and limit over-the-counter medicines and herbal remedies that may be harmful 1
• Monitor therapeutic drug levels for medications with narrow therapeutic windows 1

Common pitfall to avoid:

• Do not combine ACE inhibitor + ARB therapy—insufficient evidence for benefit and increased harm risk 3

Monitoring for CKD Complications

Regular monitoring schedule:

• Monitor urinary albumin and eGFR 1-4 times per year depending on CKD stage 2
• Check potassium periodically, especially if on ACE inhibitor/ARB, as hyperkalemia risk is elevated 1, 6, 5
• Monitor serum bicarbonate—treat metabolic acidosis when <18 mmol/L with pharmacological therapy 2, 4

Target for albuminuria reduction:

• If albuminuria ≥300 mg/g, aim for ≥30% reduction through ACE inhibitor/ARB therapy, SGLT2 inhibitors (if diabetic), and blood pressure control 2, 3
• This reduction in proteinuria directly correlates with slowed CKD progression 3

Nephrology Referral Criteria

Refer to nephrology when:

• 5-year kidney failure risk is 3-5% based on validated prediction equations 4
• eGFR <30 mL/min/1.73 m² 4
• Albuminuria ≥300 mg per 24 hours 4
• Rapid GFR decline (>5 mL/min/1.73 m² per year or >25% decline in GFR category) 3

Benefits of multidisciplinary care:

• Access to renal dietitians for specialized nutritional counseling 1, 4
• Comprehensive medication management and review 1
• Education about kidney replacement therapy options including living-donor transplantation 1

Contrast Procedures

• Ensure adequate hydration before contrast procedures to prevent contrast-induced nephropathy 3
• Recent evidence suggests intravenous contrast does not carry large risks in CKD patients—imaging studies should be performed based on clinical necessity 1

Quality of Life and Symptom Management

• Regularly screen for symptoms using validated questionnaires 1, 4
• Screen for and treat depression, which affects approximately 26.5% of patients with CKD stages 1-4 4
• Maximize health-related quality of life, physical function, capacity to work, and ability to socialize 1, 4

Evidence for Early Diagnosis and Treatment

A recorded CKD diagnosis is associated with significant improvements in management practices—annual eGFR decline decreased from 3.20 mL/min/1.73 m² before diagnosis to 0.74 mL/min/1.73 m² after diagnosis, and delayed diagnosis by 1-year increments was associated with 40% elevated risk of CKD progression to stage 4/5 9. Only 25-40% of eligible patients with CKD currently receive guideline-recommended RAS inhibitors, and uptake of SGLT2 inhibitors has been particularly slow 1, 7. Early intervention with guideline-directed medical therapy is critical to prevent progression and reduce cardiovascular mortality 7, 8, 10.