Stage 3 of Kidney Disease

In Stage 3 CKD eGFR is approximately 30-60%: eGFR 45-59 (3A) or 30-44 (3B). Remember that eGFR is an estimate (more info on eGFR) and may require a correction for (black) race.

Creatinine and eGFR in an individual are usually quite stable. Deteriorating renal function needs rapid assessment. Note that CKD staging and management outlined below are only applicable to stable renal function.

Assessment and management of Stage 3 CKD. Most Stage 3 CKD can be appropriately managed in primary care. The aim is to identify individuals at risk of progressive renal disease, and reduce associated risks.

Risk of cardiovascular events and death is substantially increased by the presence of CKD. The risk of cardiovascular death is (on average) much higher than the risk of needing dialysis or a renal transplant.
Some patients need further investigation where there are indications that progression to end stage renal failure (Stage 5) may be likely.

Initial assessment of stage 3 CKD. The aim is to identify individuals at risk of progressive renal disease, and to reduce associated risks.
Is the patient well? Is there a history of significant associated disease? Consider referral if systemic disease process involving kidneys supported by urinary abnormalities or other indicators.
If assessment is precipitated by a first discovery of elevated creatinine, it is important to be certain that the value is stable. Maybe there are previously recorded values? If not, and the patient is well, repeat test within 14 days.
Clinical assessment – especially for sepsis, heart failure, hypovolaemia, examination for bladder enlargement (imaging indicated if obstruction suspected from symptoms or examination).

Management of Stage 3 CKD
6 then 12 monthly estimation of
Creatinine and K – consider an unexplained fall in eGFR of >25% to be acute renal failure. NICE suggest seeking specialist advice for a loss in GFR over 1y of 5ml/min, or a loss of GFR in 5y of 10ml/min. More on deteriorating function
Hb – if low, exclude non-renal cause. Below 110 g/l, specific therapy may be considered. Hb falls progressively as GFR falls, but renal anaemia rarely becomes significant before stage 3B or 4 CKD. More on anaemia
Urinar y protein for ACR or PCR. Note thresholds; ACR 30 or PCR 50 for more stringent blood pressure targets (and suffix ‘p’ on CKD stage), and ACR 70 or PCR 100 for specialist referral/discussion. More on proteinuria

Cardiovascular risk – advice on smoking, exercise and lifestyle. Consider cholesterol lowering therapy if already have macrovascular disease, or if estimated 10 year risk of cardiovascular events =/>20%. More on CV risk in CKD
Immunization – influenza and pneumococcal
Medication review – regular review of medication to minimise nephrotoxic drugs (particularly NSAIDs) and ensure doses of others are appropriate to renal function.

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