Management of Chronic Kidney Disease Stage 3

Diagnostic Evaluation

The European Society of Cardiology recommends checking urine albumin-to-creatinine ratio (ACR) immediately to assess kidney damage severity and guide treatment intensity, particularly for determining the need for ACE inhibitor or ARB therapy, with ACR ≥30 mg/g indicating kidney damage requiring ACE inhibitor or ARB therapy regardless of blood pressure 1, 2
ACR ≥300 mg/g strongly indicates the need for renin-angiotensin system blockade and nephrology referral 1, 2
Persistent albuminuria predicts both cardiovascular events and progressive kidney disease 1, 2

The European Society of Cardiology recommends starting ACE inhibitor or ARB immediately if ACR ≥30 mg/g, even with normal blood pressure, as these medications reduce progressive kidney disease risk and are first-line nephroprotective agents 1, 2
SGLT2 inhibitors, such as empagliflozin, canagliflozin, or dapagliflozin, are recommended for eGFR 30 to <90 mL/min/1.73 m², as they reduce the risk of renal endpoints and cardiovascular events 1

Nephrology referral is recommended if ACR ≥30 mg/g (especially ≥300 mg/g), uncertainty about etiology of kidney disease, rapid decline in eGFR or progressive disease, or difficulty managing complications (anemia, mineral bone disease, acidosis) 2

The European Society of Cardiology recommends targeting systolic blood pressure to 130 mmHg and <130 mmHg if tolerated, but not <120 mmHg, using ACE inhibitor or ARB as first-line agent, particularly if albuminuria or left ventricular hypertrophy is present 1

Serum creatinine has limitations, as normal creatinine does not exclude significant kidney dysfunction, and is affected by muscle mass, age, gender, and nutritional status independent of GFR, therefore, eGFR calculation (CKD-EPI equation preferred) should be used rather than creatinine alone 4