Management of patients with stage 3 chronic kidney disease (CKD), defined by an estimated glomerular filtration rate (eGFR) of 30-59 ml/min/1.73 m2, involves a comprehensive approach focused on monitoring, risk factor modification, and patient education to slow progression and reduce complications. Regular follow-up in primary care should be arranged, with the frequency tailored to clinical judgement based on the individual's risk factors and disease progression 1,2,3.
Assessment and monitoring: Evaluate and manage underlying causes of CKD and reversible factors, including nephrotoxic medications, which should be reduced or stopped during acute illness to prevent acute kidney injury 1,2,3. Monitor kidney function (eGFR) and albuminuria (urinary albumin:creatinine ratio, ACR) to assess progression risk, using tools such as the 4-variable Kidney Failure Risk Equation to inform prognosis and shared decision-making 1,3.
Blood pressure control: Hypertension management is critical. For patients with ACR over 30 mg/mmol, an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) should be offered and titrated to the highest tolerated dose 1,2,3. Blood pressure targets depend on albuminuria levels: for ACR less than 70 mg/mmol, aim for systolic BP below 140 mmHg and diastolic below 90 mmHg; for ACR 70 mg/mmol or more, aim for systolic below 130 mmHg and diastolic below 80 mmHg 2,3. KDIGO guidelines suggest a uniform target of 120 mmHg systolic but recommend individualizing therapy in frail patients or those with symptomatic hypotension 1,3. Combination therapy with multiple antihypertensives may be needed, and referral to nephrology is advised if hypertension remains uncontrolled despite four drugs 2,3.
Lifestyle and dietary advice: Patients should be encouraged to stop smoking, maintain a healthy weight, and engage in regular exercise 1. Dietary advice should address salt, potassium, phosphate, and calorie intake appropriate to CKD severity, with supervision to prevent malnutrition 1. Low-protein diets (<0.6-0.8 g/kg/day) are not recommended 1.
Cardiovascular risk management: CKD patients have increased cardiovascular risk; lipid-lowering therapy should be considered according to guidelines, although specific targets may vary 1,3(Mathew et al., 2021). Cardiovascular risk assessment tools validated for the general population are not recommended for CKD patients 2,3.
Patient education and support: Provide tailored information about CKD, its progression, treatment options, and the 5-year risk of renal replacement therapy using clear, jargon-free language 1,2,3. Psychological support and access to specialist nurses or support groups should be offered to help patients cope 1. Patients should have access to their medical data to support self-management 1.
Immunizations: Offer influenza and pneumococcal vaccines to reduce infection risk 1,2.
Medication considerations: Use caution with nephrotoxic drugs and adjust doses of medications such as ACE inhibitors carefully in CKD 1,8. Avoid combining renin-angiotensin system antagonists 2,3.
In summary, stage 3 CKD management is multidisciplinary, focusing on slowing progression through blood pressure control, lifestyle modification, risk factor management, patient education, and regular monitoring, with specialist referral as needed 1,2,3. Recent literature supports the importance of individualized lipid management and cardiovascular risk reduction in this population (Mathew et al., 2021).
Key References
- NG203 - Chronic kidney disease: assessment and management
- CKS - Kidney disease - chronic
- CKS - Chronic kidney disease
- Tolvaptan SmPC
- Methoxy polyethylene glycol-epoetin beta SmPC
- Aliskiren SmPC
- Cefalexin SmPC
- Captopril SmPC
- Ivacaftor SmPC
- Phosphate SmPC
- Bendroflumethiazide SmPC
- (Levin and Stevens, 2005): Executing change in the management of chronic kidney disease: perspectives on guidelines and practice.
- (Unknown, 2015): No Title Available
- (Mathew et al., 2021): Concepts and Controversies: Lipid Management in Patients with Chronic Kidney Disease.