From the Guidelines
The treatment of chronic kidney disease stage 3b (CKD3b) should prioritize the use of ACE inhibitors or ARBs, such as lisinopril 10-40mg daily or losartan 50-100mg daily, to control blood pressure and reduce proteinuria, targeting BP <130/80 mmHg, as recommended by the American College of Physicians 1.
Key Interventions
- Dietary modifications, including sodium restriction to <2g/day, moderate protein intake (0.8g/kg/day), and potassium restriction if levels are elevated, are essential for managing CKD3b.
- Regular monitoring of kidney function, electrolytes, and proteinuria every 3-6 months is necessary to adjust treatment plans accordingly.
- Metabolic complications should be addressed with phosphate binders for hyperphosphatemia, vitamin D supplements (calcitriol 0.25-0.5mcg daily) for secondary hyperparathyroidism, and oral iron or erythropoiesis-stimulating agents for anemia if hemoglobin falls below 10g/dL.
Cardiovascular Risk Reduction
- Statin therapy (atorvastatin 20-40mg daily) is recommended for cardiovascular risk reduction in patients with CKD3b, as suggested by the KDIGO 2024 clinical practice guideline 1.
- Lifestyle modifications, including smoking cessation, weight management, and regular exercise, are also crucial for reducing cardiovascular risk.
Additional Considerations
- Nephrotoxic medications like NSAIDs should be avoided in patients with CKD3b to prevent further kidney damage.
- The use of sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists may be beneficial for patients with diabetic kidney disease, as recommended by the American Diabetes Association and the Kidney Disease: Improving Global Outcomes 1.
From the FDA Drug Label
Losartan is indicated for the treatment of diabetic nephropathy with an elevated serum creatinine and proteinuria (urinary albumin to creatinine ratio ≥300 mg/g) in patients with type 2 diabetes and a history of hypertension In this population, losartan reduces the rate of progression of nephropathy as measured by the occurrence of doubling of serum creatinine or end stage renal disease (need for dialysis or renal transplantation)
The treatment of CKD3b may involve the use of losartan in patients with type 2 diabetes and hypertension, as it has been shown to reduce the rate of progression of nephropathy 2. However, the label does not explicitly address the treatment of CKD3b in the general population, only in the context of diabetic nephropathy.
- Key points:
- Losartan is indicated for diabetic nephropathy in patients with type 2 diabetes and hypertension
- Losartan reduces the rate of progression of nephropathy in this population
- The label does not provide direct guidance on the treatment of CKD3b in the general population 2
From the Research
Treatment of CKD3b
- The treatment of chronic kidney disease (CKD) can slow its progression to end-stage renal disease (ESRD) 3.
- Blood pressure control using angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) has the greatest weight of evidence for treating CKD 3, 4.
- Glycemic control in diabetes seems likely to retard progression of CKD 3.
- For patients with established CKD and/or diabetes with albuminuria, the updated hypertension guidelines have recommended a blood pressure (BP) goal < 130/80 mmHg 4.
- ACE inhibitors should be the drugs of first choice for treating hypertension in CKD patients, and ARBs should be used if the ACE inhibitor is not tolerated 4.
- Non-dihydropyridine CCBs consistently reduce albuminuria and slow the decline in kidney function, while dihydropyridine CCBs should not be used as monotherapy in proteinuric CKD patients but always in combination with a RAAS blocker 4.
Medications for CKD3b
- Angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB) are two classes of antihypertensive drugs that act on the renin-angiotensin-aldosterone system, and have been shown to have beneficial effects on kidney outcomes and survival in people with CKD 5.
- However, the effectiveness of ACEi and ARB in the subgroup of people with early CKD (stage 1 to 3) is less certain, and the available evidence is overall of very low certainty and high risk of bias 5.
- β-Blockers have been shown to improve outcomes in patients with heart failure with reduced ejection fraction (HFrEF) in all stages of CKD, including patients on dialysis 6.
- Angiotensin receptor neprilysin inhibitor therapy was successfully used in randomized trials in patients with eGFR as low as 20 ml/min per 1.73 m2 6.
- Sodium-glucose cotransporter inhibitor therapy improved mortality and hospitalization in patients with HFrEF and CKD stages 3 and 4 (eGFR>20 ml/min per 1.73 m2) 6.
Screening and Monitoring for CKD3b
- The role of CKD screening or monitoring in improving clinical outcomes is uncertain 7.
- Evidence for CKD treatment benefit is strongest for angiotensin-converting enzyme inhibitors and angiotensin II-receptor blockers, and in patients with albuminuria combined with diabetes or cardiovascular disease 7.