Management of Stage 3b Chronic Kidney Disease

Disease Classification and Prognosis

An eGFR of 35 mL/min/1.73 m² falls within the G3b category, representing moderately to severely decreased kidney function, according to the Kidney International guidelines 1
Patients with eGFR of 35 mL/min/1.73 m² should be monitored twice annually with both eGFR and urinary albumin measurements to guide therapy, as recommended by the Diabetes Care guidelines 3, 4

Assess for CKD complications that emerge when eGFR falls below 60 mL/min/1.73 m², including measuring serum potassium, calcium, phosphorus, parathyroid hormone, and hemoglobin, as recommended by the Diabetes Care guidelines 6
Evaluate for metabolic acidosis and screen for bone mineral disease, as recommended by the Diabetes Care guidelines 3, 1
Determine the underlying cause of CKD through review of clinical context, urinalysis, and renal ultrasound, as recommended by the Kidney International guidelines 2

Refer patients to nephrology when eGFR is <30 mL/min/1.73 m² or when there are difficult management issues, such as refractory hypertension or persistent hyperkalemia, as recommended by the Diabetes Care guidelines 6
Refer patients with urinary albumin ≥300 mg/g creatinine, as recommended by the Diabetes Care guidelines 6

The American Diabetes Association recommends first-line therapy with SGLT2 inhibitor + Metformin for patients with diabetes and CKD, as stated in the Diabetes Care guidelines 7, 3, 4
SGLT2 inhibitors are strongly recommended for patients with type 2 diabetes, eGFR ≥30 mL/min/1.73 m², and urinary albumin ≥200 mg/g to reduce CKD progression and cardiovascular events, as recommended by the Diabetes Care guidelines 3, 4
Nonsteroidal mineralocorticoid receptor antagonist (finerenone) is recommended for patients with diabetes, CKD, and eGFR <60 mL/min/1.73 m² who are at increased cardiovascular risk or unable to use SGLT2 inhibitors, as recommended by the Diabetes Care guidelines 3, 4
Continue or initiate ACE inhibitor or ARB for patients with urinary albumin ≥300 mg/g creatinine, as recommended by the Diabetes Care guidelines 6
Use maximally tolerated doses of ACE inhibitors or ARBs, as demonstrated in clinical trials showing efficacy, as recommended by the Diabetes Care guidelines 5

Optimize blood pressure control to reduce CKD progression risk, with a target systolic BP <120 mmHg, as recommended by the Diabetes Care guidelines 3, 4
Intensive BP lowering with up to 30% increase in serum creatinine does not increase mortality or progressive kidney disease, as recommended by the Diabetes Care guidelines 5

Lifestyle modifications, including smoking cessation, moderate-intensity physical activity, and dietary protein restriction to maximum 0.8 g/kg/day, are recommended for patients with CKD, as recommended by the Kidney International and Diabetes Care guidelines 1, 3, 4
Statin therapy is recommended for cardiovascular risk reduction, as recommended by the Kidney International guidelines 1
Treat metabolic acidosis if present, as recommended by the Kidney International guidelines 1
Target urinary albumin reduction ≥30% from baseline, as this is associated with improved renal and cardiovascular outcomes, as recommended by the Diabetes Care guidelines 5, 3, 4

Verify appropriate medication dosing for eGFR <60 mL/min/1.73 m², as recommended by the Diabetes Care guidelines 5
Minimize exposure to nephrotoxins, including NSAIDs and iodinated contrast, as recommended by the Diabetes Care guidelines 5
Avoid medications that adversely affect CKD patients, including most calcium channel blockers and thiazolidinediones, as recommended by the Circulation guidelines 8