Stage 3 CKD
In Stage 3 CKD eGFR is approximately 30-60%: eGFR 45-59 (3A) or 30-44 (3B). Rememember 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. Pointers to progression of renal disease are:
- Proteinuria - the risk is graded, but a common cut-off for investigation is ACR>70 or PCR>100
- Haematuria of renal origin
- Declining GFR - more info
- Young age
- Long term monitoring of renal function and other parameters is indicated.
Initial assessment | Management
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 histor 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. Ideally this sample should be taken after a period of at least 12h without meat consumption, and the sample must get to the lab or be separated the same day. Deteriorating renal function needs rapid assessment.
- Clinical assessment - especially for sepsis, heart failure, hypovolaemia, examination for bladder enlargement (imaging indicated if obstruction suspected from symptoms or examination).
- Medication review - any potentially nephrotoxic drugs, or drugs that need dose alterations when GFR reduced?
- Urine tests: dipstick for blood and quantitation of proteinuria by ACR/PCR. Presence of haematuria or proteinuria may suggest progressive renal disease.
- Imaging - exclusion of obstruction is indicated in patients with singnificant urinary symptoms or other things to suggest obstruction.
- See referral by urgency
Management of Stage 3 CKD
- 6 then 12 monthly estimation of
- Creatinine and K - consider an unxexplained 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
- Blood pressure - 140/90 max (130-139/90), or 130/80 max (120-129/80) for patients with proteinuria: urinary ACR>30 or PCR>50. More on hypertension
- 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.
Patient info - Stage 3 CKD
Most patients with Stage 3 CKD are older, and only a minority go on to get more serious kidney disease. Their increased rate of cardiovascular disease (heart attacks, strokes, narrowing of other arteries) is very important. However some do go on to get severe kidney failure, and there are some pointers that make this seem more likely.
Further information about blood tests and kidney function from the Edinburgh Renal Unit website.