What is the recommended care plan for an adult with chronic kidney disease stage 3‑5?

Care Plan for Chronic Kidney Disease Stages 3-5

Adults with CKD stages 3-5 require a stage-specific, algorithmic approach that prioritizes slowing progression, managing complications, and preparing for kidney replacement therapy, with the intensity of interventions escalating as GFR declines.

Stage-Specific Clinical Action Plan

CKD Stage 3 (eGFR 30-59 mL/min/1.73 m²)

Primary Focus: Slow progression and evaluate/treat emerging complications

• Initiate SGLT2 inhibitor as first-line therapy for most patients to reduce progression risk and cardiovascular events 1
• Control blood pressure with target <120 mm Hg systolic for patients tolerant of therapy; use ACE inhibitor or ARB at maximum tolerated dose if albuminuria is present 1
• Start statin therapy (or statin/ezetimibe combination) for all patients ≥50 years to reduce cardiovascular mortality 1
• Begin monitoring for complications including anemia, bone disease, metabolic acidosis, and hyperkalemia as prevalence rises when GFR <60 mL/min/1.73 m² 1
• Refer to renal dietitian for protein restriction to 0.8 g/kg/day (avoid >1.3 g/kg/day which accelerates progression) 2, 3
• Monitor eGFR and albuminuria every 3-6 months to assess progression rate 1

CKD Stage 4 (eGFR 15-29 mL/min/1.73 m²)

Primary Focus: Aggressive complication management and preparation for kidney replacement therapy

• Continue all Stage 3 interventions with intensified monitoring 1
• Add nonsteroidal MRA (finerenone) if diabetic to further reduce progression risk 1
• Manage hyperkalemia with dietary potassium restriction (limit processed foods high in bioavailable potassium) and pharmacologic interventions as needed 1
• Treat metabolic acidosis with sodium bicarbonate to prevent protein catabolism 3
• Manage anemia with iron supplementation and consider HIF-prolyl hydroxylase inhibitors 4
• Address CKD-mineral bone disorder through phosphate restriction and vitamin D analogs 1
• Mandatory nephrology referral for all patients with GFR <30 mL/min/1.73 m² to improve outcomes and reduce mortality 1
• Begin kidney replacement therapy education including dialysis modality options and transplant evaluation 1
• Consider supervised low-protein diet (0.55-0.60 g/kg/day) for high-risk patients willing and able to adhere under close dietitian supervision 3

CKD Stage 5 (eGFR <15 mL/min/1.73 m²)

Primary Focus: Preparation for and initiation of kidney replacement therapy

• Prepare vascular access for hemodialysis or peritoneal dialysis catheter placement well before uremic symptoms develop 1
• Complete transplant evaluation if candidate 1
• Initiate dialysis when uremic symptoms appear (nausea, vomiting, encephalopathy, pericarditis) 1
• Increase protein intake to 1.0-1.2 g/kg/day once dialysis initiated to prevent malnutrition 2
• Continue cardiovascular risk reduction with statins, blood pressure control, and SGLT2 inhibitors until dialysis or transplant 1

Lifestyle and Dietary Interventions (All Stages)

Implement immediately at diagnosis:

• Plant-based Mediterranean-style diet emphasizing vegetables, fruits, whole grains, and legumes over animal protein 1
• Sodium restriction <2,300 mg/day to optimize blood pressure control 3
• Regular physical activity tailored to functional capacity 1
• Complete tobacco cessation 1
• Weight management targeting BMI 20-25 kg/m² 1

Medication Management Across All Stages

Continue until dialysis or transplant:

• SGLT2 inhibitor (empagliflozin, dapagliflozin, or canagliflozin) 1
• RAS inhibitor (ACE inhibitor or ARB) at maximum tolerated dose if hypertensive or albuminuric 1
• Moderate-to-high intensity statin (add ezetimibe if LDL not at goal) 1
• Aspirin 81 mg daily only for secondary prevention in patients with established cardiovascular disease 1
• Avoid nephrotoxins including NSAIDs, aminoglycosides, and minimize iodinated contrast exposure 1, 5

Critical Monitoring Parameters

Every 3-6 months:

• eGFR using CKD-EPI equation without race variable 5
• Urine albumin-to-creatinine ratio 1
• Serum potassium (risk of hyperkalemia with RAS inhibitors and MRAs) 1
• Hemoglobin (target >10 g/dL to prevent symptoms) 1
• Calcium, phosphorus, PTH (for CKD-MBD) 1
• Bicarbonate (treat if <22 mEq/L) 3
• Nutritional status (albumin, body weight, dietary intake) 2, 3

Common Pitfalls to Avoid

• Do not delay nephrology referral until GFR <15 mL/min/1.73 m²; late referral increases dialysis mortality 1
• Never restrict protein below 0.8 g/kg/day without mandatory renal dietitian supervision as this significantly increases malnutrition and mortality risk 2, 3
• Do not discontinue SGLT2 inhibitors due to initial eGFR dip (5-10% decline is expected and beneficial long-term) 1
• Avoid holding ACE inhibitors/ARBs for modest creatinine increases (<30% rise); benefits outweigh risks 1
• Do not prescribe very low-protein diets (<0.6 g/kg/day) without keto-acid analog supplementation as mortality increases without supplementation (HR 1.92) 3
• Never implement protein restriction in metabolically unstable patients, those with existing malnutrition, or children 2, 3

Referral Thresholds

Immediate nephrology referral indicated for:

• All patients with eGFR <30 mL/min/1.73 m² (Stage 4-5) 1
• Rapid progression (eGFR decline >5 mL/min/1.73 m²/year) 1
• Albuminuria >300 mg/g despite RAS inhibitor therapy 1
• Difficult-to-control hypertension requiring ≥4 agents 1
• Unexplained hematuria or active urinary sediment 1

Multidisciplinary team involvement:

• Renal dietitian for all patients with Stage 3-5 CKD 2, 3
• Pharmacist for medication reconciliation and dosing adjustments 1
• Social worker for advance care planning and transplant evaluation 6
• Diabetes educator if diabetic kidney disease 1