Management of Chronic Kidney Disease Stage 3

Blood Pressure Management

The American Heart Association recommends a target blood pressure of less than 130/80 mmHg for patients with CKD stage 3 1
First-line therapy should include either Angiotensin-converting enzyme (ACE) inhibitors or Angiotensin II receptor blockers (ARBs) if ACE inhibitors are not tolerated, as recommended by the American College of Cardiology 1, 2, 3
Blood pressure should be monitored regularly, preferably with 24-hour ambulatory devices for accurate assessment, as suggested by the Kidney International journal 4

For patients aged ≥50 years with CKD stage 3, statin or statin/ezetimibe combination therapy is strongly recommended (Grade 1A) by the Kidney International journal 5, 6, 7
For patients aged 18-49 years with CKD stage 3, statin therapy is suggested if they have known coronary disease, diabetes mellitus, prior ischemic stroke, or estimated 10-year cardiovascular risk >10%, as recommended by the Kidney International journal 4, 5, 7, 8
Low-dose aspirin is recommended for secondary prevention in patients with established cardiovascular disease by the Kidney International journal 7, 9

A plant-based "Mediterranean-style" diet is recommended in addition to pharmacological therapy by the Kidney International journal 7, 9
Sodium restriction is recommended to help control blood pressure, as suggested by the Kidney International journal 4
Limiting alcohol, meats, and high-fructose corn syrup intake is recommended by the Kidney International journal 9

The American Journal of Kidney Diseases recommends reviewing all medications for appropriate dosing in CKD stage 3 8
Nephrotoxic medications, particularly NSAIDs, should be avoided, as recommended by the Kidney International journal 9
Metformin should be used with caution or avoided if serum creatinine ≥1.5 mg/dL in men or ≥1.4 mg/dL in women, as suggested by the American Journal of Kidney Diseases 8

For patients with diabetes, glycemic control is important but requires careful monitoring due to increased risk of hypoglycemia in CKD, as recommended by the American Journal of Kidney Diseases 8
For patients with atrial fibrillation, non-vitamin K antagonist oral anticoagulants (NOACs) are preferred over warfarin, with appropriate dose adjustments based on kidney function, as recommended by the Kidney International journal 4, 9

The American Heart Association recommends target blood pressure should be less than 130/80 mmHg for all patients with CKD stage 3 10
First-line pharmacotherapy should include an ACE inhibitor or ARB, particularly when albuminuria is present (≥300 mg/day) 11, 10
An ACE inhibitor is reasonable to slow kidney disease progression in CKD stage 3 or higher 10
Monitor for postural hypotension regularly when treating with BP-lowering medications 12
Avoid using the combination of an ACE inhibitor and an ARB together due to increased risk of adverse events 11

Consider referral to nephrology for patients with CKD stage 3 who have rapid decline in GFR 13
Consider referral to nephrology for patients with CKD stage 3 who have significant albuminuria (>300 mg/day), refractory hypertension, persistent electrolyte abnormalities, recurrent nephrolithiasis, or hereditary kidney disease 14
Remember that most patients with stage 3 CKD die from cardiovascular causes rather than progressing to end-stage renal disease, making cardiovascular risk reduction paramount 14