What vaccinations and additional preventive measures should be given to a patient with stage 3 chronic kidney disease (eGFR 30–59 mL/min/1.73 m²) and albumin‑to‑creatinine ratio ≥300 mg/g (A3)?

Management of Stage 3, A3 CKD: Vaccinations and Preventive Care

All adults with Stage 3 CKD and severe albuminuria (A3, ≥300 mg/g) require comprehensive vaccination and should be managed with heightened attention to cardiovascular risk, medication safety, and nephrology referral planning.

Vaccination Requirements

Influenza Vaccination

• Administer annual influenza vaccination to all adults with CKD unless contraindicated 1
• This is a Grade 1B recommendation applicable to all CKD stages 1

Pneumococcal Vaccination

• Administer polyvalent pneumococcal vaccine to all adults with eGFR <30 mL/min/1.73 m² (Stage 3b with eGFR 30-44) and those at high risk including patients with nephrotic syndrome, diabetes, or receiving immunosuppression 1
• For Stage 3a patients (eGFR 45-59), vaccination is indicated if nephrotic-range proteinuria or other high-risk conditions are present 1
• Revaccinate within 5 years of initial pneumococcal vaccination 1

Hepatitis B Vaccination

• Immunize all adults at high risk of CKD progression with eGFR <30 mL/min/1.73 m² (Stage 3b) against hepatitis B 1
• Confirm response with appropriate serological testing 1
• This is particularly critical for patients who may progress to dialysis 1

Live Vaccine Considerations

• Assess the patient's immune status before administering live vaccines 1
• Follow recommendations from official governmental bodies regarding live vaccine administration 1

Critical Non-Vaccination Management Issues

Cardiovascular Risk Reduction (Primary Concern)

Stage 3 CKD patients with A3 albuminuria have markedly elevated cardiovascular mortality risk that exceeds their risk of progression to dialysis 2, 3

• Initiate or optimize ACE inhibitor or ARB therapy targeting blood pressure ≤130/80 mmHg 1, 2
• ACE inhibitors or ARBs are strongly recommended for albuminuria ≥300 mg/g regardless of baseline blood pressure 2
• Accept creatinine increases ≤30% from baseline when initiating renin-angiotensin system blockade—this is expected and acceptable 2
• Do not discontinue ACE inhibitor/ARB for creatinine increases ≤30% in the absence of volume depletion 4

SGLT2 Inhibitor Therapy (If Diabetic)

• Initiate SGLT2 inhibitor (e.g., dapagliflozin 10 mg daily) in all diabetic patients with Stage 3 CKD and eGFR ≥25 mL/min/1.73 m² to reduce CKD progression and cardiovascular events 1, 5, 2
• This recommendation applies specifically to patients with albuminuria ≥200 mg/g 1
• Continue SGLT2 inhibitor regardless of other medication use 5

Target Albuminuria Reduction

• Aim for ≥30% reduction in albuminuria through ACE inhibitor/ARB therapy, SGLT2 inhibitors (if diabetic), and blood pressure control 1, 2
• This reduction directly correlates with slowed CKD progression 2
• Monitor urine albumin-to-creatinine ratio to assess treatment response 2

Medication Safety

NSAIDs are contraindicated in Stage 3b CKD and should be avoided completely 5, 2

• NSAIDs significantly increase acute kidney injury risk and accelerate CKD progression 2
• Never combine NSAIDs with ACE inhibitors/ARBs and diuretics ("triple whammy") as this markedly increases acute kidney injury risk 5

Safer analgesic alternatives:

• First-line: Acetaminophen up to 3 g/day (no dose adjustment needed) 5
• Second-line: Topical NSAIDs (diclofenac or ibuprofen gel) with minimal systemic absorption 5
• Third-line: Tramadol 50 mg every 12 hours (max 200 mg/day) for severe pain 5

Medication dose adjustments:

• Estimate creatinine clearance and adjust doses of all renally cleared medications 2
• For Stage 3b: Reduce metformin maximum dose to 1,000 mg/day; discontinue if eGFR falls <30 mL/min/1.73 m² 5

Dietary Modifications

• Restrict dietary protein to maximum 0.8 g/kg/day 1, 2
• Limit sodium intake to <2 g/day to improve blood pressure control and reduce proteinuria 4, 2
• These dietary interventions enhance the efficacy of pharmacologic therapy 4

Monitoring Requirements

• Monitor serum creatinine, eGFR, and potassium regularly to detect further kidney function decline 4, 2
• For patients on ACE inhibitors/ARBs with diuretics, monitor creatinine and potassium closely 4
• Check hemoglobin at least annually in Stage 3a; at least twice yearly in Stage 3b 1
• Measure serum calcium, phosphate, PTH, and alkaline phosphatase at least once in Stage 3b (eGFR <45 mL/min/1.73 m²) to establish baseline values 1

Acute Kidney Injury Prevention

• All people with CKD are at increased risk of acute kidney injury 1
• Ensure adequate hydration before contrast procedures to prevent contrast-induced nephropathy 2
• Follow KDIGO AKI guideline recommendations during intercurrent illness or procedures that increase AKI risk 1
• Avoid volume depletion from excessive diuresis 4

Nephrology Referral Criteria

Refer to nephrology if:

• eGFR declines to <30 mL/min/1.73 m² (progression to Stage 4) 1, 4
• Rapid GFR decline (>5 mL/min/1.73 m² per year or >25% decrease in eGFR category) 4, 2
• Refractory edema despite adequate diuretic therapy 4
• Uncertainty about etiology of kidney disease 1
• Difficult management issues 1

Common Pitfalls to Avoid

• Do not withhold ACE inhibitors/ARBs due to fear of creatinine elevation—small increases (≤30%) are expected and acceptable 2
• Do not delay SGLT2 inhibitor initiation in diabetic patients—these provide proven kidney and cardiovascular protection 2
• Do not overlook albuminuria assessment—this is the single most important prognostic factor and treatment target 2, 3
• Do not use combination ACE inhibitor + ARB therapy—insufficient evidence for benefit and increased harm risk 2

Prognosis Context

Approximately 50% of Stage 3 CKD patients progress to Stage 4 or 5 over 10 years 6. Stage 3b patients (eGFR 30-44) have significantly higher risks of adverse renal and cardiovascular outcomes than Stage 3a patients (eGFR 45-59) 6. Macroalbuminuria (HR 3.06), microalbuminuria (HR 1.99), and Stage 3b classification (HR 2.99) are independent predictors of progression 6. Patients with Stage 3 CKD and albuminuria >30 mg/24h have increased cardiovascular event rates comparable to or exceeding those with lower eGFR but no albuminuria 3.