From the Guidelines
Chronic Kidney Disease (CKD) stage 3T management should prioritize preserving transplant function and preventing progression, with a focus on controlling blood pressure, monitoring kidney function, and implementing lifestyle modifications to support overall kidney health, as recommended by the most recent guidelines 1.
Key Management Strategies
- Blood pressure control: target levels below 130/80 mmHg using ACE inhibitors or ARBs as first-line agents
- Regular monitoring of kidney function: creatinine and estimated glomerular filtration rate (eGFR) every 3-6 months
- Kidney-friendly diet: moderately restricting sodium (less than 2.3g daily), phosphorus, and potassium if levels are elevated
- Medication adjustments: as kidney function changes, and avoiding nephrotoxic medications
- Annual screening: for proteinuria, anemia, and metabolic bone disease
- Lifestyle modifications: regular exercise, maintaining healthy weight, avoiding smoking, and limiting alcohol consumption
Referral to Nephrologist
Referral to a nephrologist is recommended for patients with CKD stage 3T if the primary care provider is unable to adequately evaluate and treat the patient, or if the patient's GFR is less than 30 mL/min per 1.73 m², as suggested by the Canadian Society of Nephrology commentary on the KDIGO clinical practice guideline for CKD evaluation and management 1.
Recent Guidelines
The most recent guidelines, such as the diabetic kidney disease management field guide for health care professionals in the 21st century, highlight the importance of early detection and management of CKD, and recommend the use of newer classes of glucose-lowering agents, such as sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists, to reduce the risk of progression of kidney disease and cardiovascular mortality 1.
From the FDA Drug Label
5.3 Renal Function Deterioration Changes in renal function including acute renal failure can be caused by drugs that inhibit the renin-angiotensin system and by diuretics. Patients whose renal function may depend in part on the activity of the renin-angiotensin system (e.g., patients with renal artery stenosis, chronic kidney disease, severe congestive heart failure, or volume depletion) may be at particular risk of developing acute renal failure on losartan.
CKD 3 patients are at particular risk of developing acute renal failure on losartan, as their renal function may depend in part on the activity of the renin-angiotensin system.
- Monitor renal function periodically in these patients.
- Consider withholding or discontinuing therapy in patients who develop a clinically significant decrease in renal function on losartan 2.
From the Research
CKD 3T Overview
- CKD 3T refers to stage 3 chronic kidney disease, which is defined as a glomerular filtration rate (GFR) of 30-59 mL/min/1.73 m2 3.
- At this stage, patients are at increased risk of cardiovascular disease, end-stage kidney disease, and death.
- Appropriate management of CKD 3T includes cardiovascular risk reduction, treatment of albuminuria, avoidance of potential nephrotoxins, and adjustments to drug dosing.
Blood Pressure Management
- Blood pressure control is crucial in patients with CKD 3T to reduce cardiovascular risk and renal disease progression 4.
- A blood pressure target of less than 140/90 mm Hg is generally recommended, although some patients may benefit from more aggressive blood pressure control.
- In patients with CKD and proteinuria, a target systolic blood pressure of 120-130 mm Hg and diastolic blood pressure of 70-80 mm Hg may be beneficial.
Treatment Options
- Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) are commonly used to treat CKD 3T, as they can help reduce urine albumin excretion and slow disease progression 5.
- Combination therapy with ACEIs and ARBs may be more effective than monotherapy in reducing urine albumin excretion and urine protein excretion.
- However, combination therapy may also increase the risk of hyperkalemia and hypotension.
Alternative Therapies
- Losartan, an ARB, may be used as an alternative to ACE inhibitors in patients with renal dysfunction, although it may not be better tolerated in terms of renal toxicity 6.
- Monitoring of renal function is essential when using losartan or ACE inhibitors in patients with underlying renal dysfunction.
Managing Adverse Effects
- ACE inhibitors and ARBs can cause declining renal function and hyperkalemia, particularly in patients with underlying renal dysfunction 7.
- Regular monitoring of potassium levels and renal function is necessary to minimize the risk of adverse effects.
- Adjustments to drug dosing and the use of alternative therapies may be necessary in some patients to manage adverse effects.