What is the next step for a 66-year-old male with hypertension (HTN) and impaired renal function, as indicated by an eGFR of 35, who uses NSAIDs daily?

Management of a 66-Year-Old Male with HTN, Daily NSAID Use, and Impaired Renal Function

The immediate next step for this patient is to discontinue all NSAIDs due to their nephrotoxic effects in a patient with significantly impaired renal function (eGFR 35) and refer to nephrology for evaluation of chronic kidney disease. 1

Assessment of Current Situation

This 66-year-old male presents with:

• Hypertension (HTN)
• Daily NSAID use
• eGFR of 35 on two separate measurements two weeks apart
• No symptoms of urinary changes or LUTS (lower urinary tract symptoms)

An eGFR of 35 ml/min/1.73m² indicates Stage 3b chronic kidney disease, which requires prompt intervention to prevent further deterioration.

Management Algorithm

1. Immediate Discontinuation of NSAIDs

   • All NSAIDs should be stopped immediately as they can cause volume-dependent renal failure, interstitial nephritis, and nephritic syndrome 1
   • The patient's age (>60 years) and hypertension place him at particularly high risk for NSAID-related renal complications 1

2. Alternative Pain Management

   • Replace NSAIDs with acetaminophen (up to 3g daily) for pain management 1
   • Consider topical analgesics if pain is localized
   • For moderate to severe pain, consider opioid analgesics which are safer alternatives for renal function 1

3. Nephrology Referral

   • Prompt referral to nephrology for comprehensive evaluation and management of chronic kidney disease
   • This should occur within 1-2 weeks given the severity of renal impairment

4. Additional Laboratory Testing

   • Complete renal panel including electrolytes, BUN, creatinine
   • Urinalysis with microscopy to assess for proteinuria, hematuria
   • Urine protein-to-creatinine ratio
   • Consider renal ultrasound to evaluate kidney structure

5. Blood Pressure Management

   • Optimize antihypertensive therapy
   • Target BP <130/80 mmHg for patients with CKD
   • Consider medications that provide renoprotection (ACE inhibitors or ARBs) if not already prescribed

Monitoring and Follow-up

• Recheck renal function (BUN, creatinine, eGFR) within 2 weeks after NSAID discontinuation

  • Significant improvement in renal function can occur after stopping NSAIDs 2
  • Studies show eGFR can increase from 45.9 to 46.9 ml/min/1.73m² in stage 3 CKD patients who discontinue NSAIDs 2

• Monitor for electrolyte abnormalities, particularly hyperkalemia

• Assess fluid status and adjust medications accordingly

Important Considerations

• NSAID Nephrotoxicity: All NSAIDs, including COX-2 inhibitors, can cause renal complications through inhibition of prostaglandin synthesis 1

• Risk Factors: This patient has multiple risk factors for NSAID-induced kidney injury:

  • Age >60 years
  • Hypertension
  • Pre-existing renal impairment (eGFR 35)

• Reversibility: While acute NSAID-related kidney injury is often reversible upon drug withdrawal, chronic use may lead to permanent kidney damage 3

Common Pitfalls to Avoid

• Continuing NSAIDs at a lower dose: Even "renal-sparing" NSAIDs should be avoided in patients with this level of renal impairment 4
• Delaying nephrology referral: CKD at this stage requires specialist input
• Inadequate monitoring: Renal function should be closely monitored after NSAID discontinuation
• Ignoring other nephrotoxic agents: Review all medications for potential nephrotoxicity
• Focusing only on pain management: The underlying cause of the patient's pain should be addressed with safer alternatives

By discontinuing NSAIDs and implementing appropriate management, there is potential for improvement in renal function and prevention of further kidney damage in this patient.