What is the management plan for a patient with impaired renal function, specifically a Glomerular Filtration Rate (GFR) of 36?

From the Guidelines

A patient with a GFR of 36 ml/min/1.73m² has Stage 3b chronic kidney disease (CKD) and requires comprehensive management. Treatment should focus on slowing disease progression, managing complications, and preventing cardiovascular events. Blood pressure control is essential, targeting <130/80 mmHg using ACE inhibitors or ARBs (such as lisinopril 10-40 mg daily or losartan 25-100 mg daily) as first-line agents due to their renoprotective effects, as recommended by the National Kidney Foundation practice guidelines for chronic kidney disease: evaluation, classification, and stratification 1.

Key Management Strategies

• Medication dosages should be adjusted for reduced renal function, with particular caution for NSAIDs, certain antibiotics like aminoglycosides, and metformin.
• Regular monitoring should include quarterly blood tests for electrolytes, creatinine, and eGFR, along with urine albumin-to-creatinine ratio assessment.
• Dietary modifications are important, including moderate protein restriction (0.8 g/kg/day), sodium limitation (<2.3 g/day), and potassium restriction if levels are elevated, as suggested by the standards of medical care for type 2 diabetes in China 2019 1.
• Patients should be screened for anemia, metabolic bone disease, and acidosis, with treatment initiated as needed.
• Erythropoiesis-stimulating agents may be considered if hemoglobin falls below 10 g/dL.
• Nephrology referral is appropriate at this stage to establish specialized care and prepare for potential disease progression, as a nephrologist should participate in the care of patients with a GFR less than 30 mL/min per 1.73 m² (level B recommendation) 1.
• Cardiovascular risk reduction through statin therapy and lifestyle modifications is crucial, as CKD significantly increases cardiovascular event risk.

Considerations for Referral and Care

• The guidelines endorse a model in which primary physicians and specialists share responsibility for the care of persons with chronic kidney disease, with the need for consultation and comanagement with nephrologists increasing as kidney disease worsens 1.
• Late referral is associated with increased mortality after initiation of dialysis, highlighting the importance of timely referral to a nephrologist 1.

Given the most recent and highest quality evidence, the management plan for a patient with a GFR of 36 should prioritize comprehensive care, including blood pressure control, medication adjustment, regular monitoring, dietary modifications, and screening for complications, with referral to a nephrologist for specialized care 1.

From the FDA Drug Label

8.7 Renal Impairment Patients with renal insufficiency have elevated plasma concentrations of losartan and its active metabolite compared to subjects with normal renal function. No dose adjustment is necessary in patients with renal impairment unless a patient with renal impairment is also volume depleted

The management plan for a patient with a Glomerular Filtration Rate (GFR) of 36 should consider the potential for elevated plasma concentrations of losartan and its active metabolite.

• No dose adjustment is necessary in patients with renal impairment unless the patient is also volume depleted.
• It is essential to monitor renal function and electrolytes in patients with renal impairment taking losartan.
• Avoid combined use of RAS inhibitors, such as aliskiren with losartan, in patients with renal impairment (GFR <60 mL/min) 2.

From the Research

Management Plan for a Patient with Impaired Renal Function (GFR 36)

• The patient's GFR of 36 indicates impaired renal function, which requires careful management to slow disease progression and prevent complications 3, 4.
• According to the studies, patients with a GFR <30 ml/min/1.73 m(2) are often referred to a nephrologist for further evaluation and management 3, 4.
• However, some studies suggest that patients with stable early CKD (GFR > 30 ml/min) can be discharged from nephrology clinics to primary care for monitoring, as long as they receive appropriate monitoring of renal function 5.
• The management plan for a patient with a GFR of 36 may include:
  • Regular monitoring of renal function, including measurements of GFR and albuminuria 6, 5.
  • Control of blood pressure and proteinuria using angiotensin receptor blockers (ARBs) or other medications 7.
  • Lifestyle modifications, such as dietary changes and exercise, to slow disease progression 4.
  • Referral to a nephrologist if there are signs of rapid decline in GFR or other complications 3, 4.

Key Considerations

• The patient's GFR of 36 indicates a moderate level of renal impairment, which requires careful monitoring and management to prevent progression to end-stage renal disease 3, 4.
• The choice of medication and management strategy will depend on the patient's individual needs and medical history, including the presence of diabetes, hypertension, or other comorbidities 7.
• Regular communication and collaboration between the patient's primary care physician and nephrologist are essential to ensure optimal management and prevent complications 3, 5.