Chronic Kidney Disease Stages 3-5 Management

Initial Diagnostic Confirmation and Classification

The American College of Physicians recommends confirming CKD by repeating abnormal eGFR or albuminuria tests after 3 months to distinguish from acute kidney injury 1
Chronicity can also be established through review of past measurements, imaging showing reduced kidney size or cortical thinning, kidney biopsy findings of fibrosis, or medical history of conditions causing CKD 1
The National Kidney Foundation suggests classifying all CKD patients using three dimensions simultaneously: cause, GFR category, and albuminuria category 1
Establish etiology through clinical context, personal and family history, social and environmental factors, medications, physical examination, laboratory measures, imaging, and when indicated, genetic testing or kidney biopsy 2, 1

The American Journal of Kidney Diseases recommends serum creatinine for eGFR calculation and spot urine albumin-to-creatinine ratio (ACR) 1
Complete metabolic panel, complete blood count, lipid panel, hemoglobin A1c, parathyroid hormone, and 25-hydroxyvitamin D are essential initial tests 1

Use externally validated risk equations to estimate absolute risk of kidney failure in patients with CKD G3-G5 1
The American College of Cardiology recommends using externally validated models developed within CKD populations or that incorporate both eGFR and albuminuria for cardiovascular risk prediction 1
5-year kidney failure risk of 3-5% triggers nephrology referral consideration; 2-year risk >10% indicates need for multidisciplinary care; 2-year risk >40% mandates preparation for kidney replacement therapy 1

The American Journal of Kidney Diseases suggests initiating ACE inhibitor or ARB, usually in combination with a diuretic, for hypertensive patients with diabetes and CKD stages 1-4 4
Target blood pressure <130/80 mmHg for patients with albuminuria ≥30 mg/24 hours 5
Add SGLT2 inhibitors to RAS inhibition for diabetic nephrosclerosis with eGFR ≥20 mL/min/1.73 m² 5, 6

Begin evaluation and treatment of complications when GFR declines to <60 mL/min/1.73 m² (stage 3) 3
Monitor for hypertension, cardiovascular disease risk factors, and manifestations at all stages 3
Screen regularly for diabetic retinopathy, neuropathy, and foot complications 6

eGFR <30 mL/min/1.73 m² (stage 4-5) mandates immediate nephrology referral 1, 5
ACR ≥300 mg/g, rapid decline in eGFR, uncertainty about kidney disease etiology, resistant hypertension, and significant albuminuria increases despite good blood pressure control require immediate referral 1, 5

Restrict sodium intake to <2 g per day (<90 mmol/day or <5 g sodium chloride/day) 5, 6
Limit protein intake to 0.8 g/kg body weight/day for stage 3 or higher CKD not on dialysis 5, 6
Recommend Mediterranean-style diet to reduce cardiovascular risk 5

Avoid nephrotoxins including NSAIDs, aminoglycosides, contrast agents, and proton pump inhibitors when possible 1
Adjust medication dosing based on eGFR for renally cleared drugs 1
Review all medications for potential nephrotoxicity or need for dose adjustment 3

Provide structured, monitored, individualized patient education regarding dialysis options and transplantation 6
Preparations for kidney replacement therapy should begin when GFR declines to <15 mL/min/1.73 m² (stage 5) 3, 6