What is the recommended management for a 51-year-old black female with impaired renal function, as indicated by an eGFR of 62?

From the Guidelines

For a 51-year-old Black female with an eGFR of 62 mL/min/1.73m², the recommended management includes regular monitoring of kidney function every 6-12 months and addressing modifiable risk factors, as indicated by the most recent guidelines 1. This patient has Stage 3 chronic kidney disease (mild to moderate kidney damage with decreased function), and the management should focus on slowing the progression of kidney disease and reducing the risk of cardiovascular complications.

Key Management Strategies:

• Blood pressure should be controlled to a target of <130/80 mmHg, preferably with an ACE inhibitor like lisinopril (starting at 5-10 mg daily) or an ARB such as losartan (25-50 mg daily), as these medications provide renoprotective effects beyond blood pressure control 1.
• Diabetes, if present, should be managed to maintain HbA1c <7%, as intensive glycemic control has been shown to delay the onset and progression of albuminuria and reduced eGFR in patients with type 1 and type 2 diabetes 1.
• A low-sodium diet (less than 2.3g daily) is recommended, along with moderate protein intake (0.8g/kg/day), to reduce the risk of kidney disease progression.
• The patient should avoid nephrotoxic medications including NSAIDs and certain antibiotics, as these can cause further kidney damage.
• Regular screening for albuminuria with urine albumin-to-creatinine ratio is important to monitor disease progression, and surveillance should be done regularly to enable timely diagnosis of CKD, monitor progression of CKD, detect superimposed kidney diseases including AKI, assess risk of CKD complications, dose drugs appropriately, and determine whether nephrology referral is needed 1.
• Lifestyle modifications including regular exercise, weight management, smoking cessation, and limited alcohol consumption are essential components of care.
• Early nephrology referral should be considered if there is rapid decline in eGFR (>5 mL/min/year) or development of significant proteinuria, as indicated by the guidelines 1.

From the FDA Drug Label

Impaired renal function decreases elimination of lisinopril, which is excreted principally through the kidneys, but this decrease becomes clinically important only when the glomerular filtration rate is below 30 mL/min. The patient's eGFR is 62, which is above the threshold of 30 mL/min.

• Dose adjustment may not be necessary based on the provided eGFR value.
• Monitoring of renal function and cautious use of the medication are still recommended.
• The patient's renal function should be closely monitored while taking lisinopril 2.

From the Research

Patient Profile

• Age: 51 years
• Sex: Female
• Ethnicity: Black
• Lab values:
  • Creatinine: 1.09
  • BUN: 12
  • eGFR: 62

Implications of Impaired Renal Function

• The patient's eGFR of 62 indicates mildly to moderately decreased kidney function, which is associated with an increased risk of kidney failure, cardiovascular disease (CVD), and all-cause death 3.
• The risk of CVD and mortality is higher in older populations with decreased eGFR, regardless of proteinuria 3, 4.

Management of Impaired Renal Function

• Angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB) are commonly used to manage patients with early chronic kidney disease (CKD) 5, 6.
• However, the effectiveness of ACEi and ARB in patients with stage 1 to 3 CKD who do not have diabetes mellitus is uncertain 5.
• The use of ACEi and ARB in advanced CKD is also debated, with some studies suggesting that they may not be superior to other antihypertensive agents in reducing cardiovascular events 6.
• Patients with decreased eGFR should be monitored for hyperkalemia, particularly when using ACEi or ARB, as the risk of hyperkalemia increases with declining GFR 7.

Recommended Management

• Regular monitoring of kidney function, blood pressure, and electrolyte levels is essential for patients with impaired renal function.
• The use of ACEi or ARB should be considered on a case-by-case basis, taking into account the patient's individual risk factors and medical history.
• Patients with decreased eGFR should be educated on the importance of adhering to their medication regimen and attending regular follow-up appointments to monitor their condition.