What is the treatment plan for a patient with stage 3b Chronic Kidney Disease (CKD)?

From the Guidelines

For a patient with stage 3b chronic kidney disease (CKD), I recommend implementing a comprehensive management plan focused on slowing disease progression and managing complications, with a primary goal of blood pressure control targeting a systolic BP range of 130–139 mmHg, as recommended by the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1. The plan should include lifestyle advice and BP-lowering medication, with individualized treatment considered according to its tolerability and impact on renal function and electrolytes. Key components of the plan include:

• Blood pressure control with medication, preferably with a RAS blocker such as an ACE inhibitor or ARB, which has been shown to be more effective at reducing albuminuria than other antihypertensive agents 1
• Dietary modifications, including sodium restriction to <2g daily, moderate protein intake of 0.8g/kg/day, and potassium restriction if hyperkalemic, as recommended for persons with early stages of CKD 1
• Monitoring and managing metabolic complications with laboratory testing every 3-6 months, including comprehensive metabolic panel, complete blood count, phosphorus, PTH, and vitamin D levels
• Consideration of erythropoiesis-stimulating agents for anemia if hemoglobin falls below 10 g/dL
• Addressing mineral bone disorder with phosphate binders and vitamin D supplementation as needed
• Statin therapy regardless of baseline lipid levels, such as atorvastatin 20 mg daily
• Lifestyle modifications, including smoking cessation, weight management, regular exercise, and avoidance of nephrotoxic medications (NSAIDs, aminoglycosides) Referral to a nephrologist is appropriate at this stage for specialized management and preparation for potential future renal replacement therapy. It is also important to note that individualized BP targets are recommended for those with lower eGFR or renal transplantation, and that the use of ACE inhibitors or ARBs is recommended as part of the treatment strategy in hypertensive patients with microalbuminuria or proteinuria 1.

From the FDA Drug Label

For adult patients with CKD not on dialysis: • Consider initiating RETACRIT treatment only when the hemoglobin level is less than 10 g/dL and the following considerations apply: o The rate of hemoglobin decline indicates the likelihood of requiring a RBC transfusion and, o Reducing the risk of alloimmunization and/or other RBC transfusion-related risks is a goal • If the hemoglobin level exceeds 10 g/dL, reduce or interrupt the dose of RETACRIT, and use the lowest dose of RETACRIT sufficient to reduce the need for RBC transfusions. • The recommended starting dose for adult patients is 50 to 100 Units/kg 3 times weekly intravenously or subcutaneously.

The plan for a stage 3b CKD patient is to consider initiating RETACRIT treatment when the hemoglobin level is less than 10 g/dL, with a starting dose of 50 to 100 Units/kg 3 times weekly intravenously or subcutaneously, and to use the lowest dose sufficient to reduce the need for RBC transfusions 2.

• Key considerations for initiating treatment include the rate of hemoglobin decline and the risk of alloimmunization and other RBC transfusion-related risks.
• Dose adjustment should be based on hemoglobin levels, with a goal of maintaining a level sufficient to reduce the need for RBC transfusions.

From the Research

Stage 3b CKD Plan

• The ideal blood pressure goal for patients with stage III or higher chronic kidney disease (CKD) is less than 140/90 mm Hg 3, 4.
• In patients with CKD and proteinuria of more than 1 g/day, a target systolic BP of 120 to 130 mm Hg and diastolic BP of 70 to 80 mm Hg may yield the greatest benefit while avoiding most of the adverse cardiovascular outcomes associated with lower levels of BP 3.
• Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin-receptor blockers (ARBs) are effective in reducing urine albumin excretion and urine protein excretion in patients with CKD 5, 6.
• The combination of ACEIs and ARBs may be more effective than high-dose ACEIs or ARBs in reducing urine albumin excretion and urine protein excretion, without decreasing glomerular filtration rate (GFR) and increasing the incidence of hyperkalemia 5.
• However, the combination of ACEIs and ARBs may increase the risk of hypotension, and close surveillance of renal function and blood pressure is necessary during such therapy 5, 7.

Medication Considerations

• ACEIs and ARBs are recommended for patients with CKD, especially those with proteinuria 3, 4, 5, 6.
• The choice of medication and dosage should be individualized based on the patient's specific needs and medical history 5, 7.
• Regular monitoring of blood pressure, renal function, and electrolyte levels is necessary to minimize the risk of adverse effects 5, 7.