How to manage a patient with impaired renal function, hyperkalemia, and poor glycemic control?

Management of Patient with eGFR 22, Hyperkalemia, and Poor Glycemic Control

This patient with severe CKD (eGFR 22), persistent hyperkalemia, and poor glycemic control (A1C >8%) requires prompt nephrology referral, continuation of furosemide for hyperkalemia management, and careful adjustment of the Ozempic dose to 1 mg weekly as prescribed.

Renal Function Management

Nephrology Referral

• Immediate nephrology referral is essential for this patient with stage 4 CKD (eGFR 22 ml/min/1.73m²) 1
• Specialist care is critical as the patient has multiple complications:
  • Persistent hyperkalemia
  • Poor glycemic control
  • Rapidly declining renal function

Hyperkalemia Management

• Continue furosemide (Lasix) as prescribed to help manage hyperkalemia 2
• Furosemide promotes potassium excretion through increased urine output and is appropriate for patients with hyperkalemia and reduced GFR 2
• Additional measures to manage hyperkalemia:
  • Dietary potassium restriction (advise patient to avoid high-potassium foods)
  • Avoid potassium supplements and potassium-based salt substitutes 2
  • Avoid medications that can worsen hyperkalemia (NSAIDs, potassium-sparing diuretics) 2, 3

Medication Review

• Review all current medications for potential nephrotoxicity
• If patient is on ACE inhibitors or ARBs:
  • Consider dose reduction if hyperkalemia persists despite diuretic therapy 2
  • May need to discontinue if severe hyperkalemia (>6.0 mmol/L) persists 2
• Monitor serum potassium and renal function within 1 week after medication adjustments 2

Diabetes Management

Glycemic Control

• Increasing Ozempic (semaglutide) to 1 mg weekly is appropriate despite reduced renal function 2, 4
  • GLP-1 receptor agonists like semaglutide can be used with no dose adjustment in patients with eGFR >15 ml/min/1.73m² 2
  • Semaglutide may provide cardiovascular benefits in addition to glycemic control 4

Glycemic Monitoring

• Recommend more frequent blood glucose monitoring to prevent hypoglycemia 2
• Target a slightly higher A1C goal (7-8%) in this patient with advanced CKD to avoid hypoglycemia 2

Other Diabetes Medications

• If patient is on metformin, it should be discontinued due to eGFR <30 ml/min/1.73m² 2
• Avoid sulfonylureas or use with extreme caution due to hypoglycemia risk 2
• If additional glycemic control is needed, consider:
  • Insulin (may require dose reduction with CKD) 2
  • DPP-4 inhibitors (with appropriate dose adjustment) 2

Patient Education and Follow-up

Patient Education

• Explain the significance of worsening kidney function and need for nephrology care
• Emphasize importance of medication adherence, especially furosemide for hyperkalemia
• Provide dietary guidance on potassium restriction and diabetes management
• Educate on signs/symptoms of hyperkalemia to report (muscle weakness, palpitations)

Follow-up Plan

• Laboratory testing in one week as recommended:
  • Serum potassium
  • Renal function panel
  • Blood glucose levels
• Ensure prompt nephrology appointment is scheduled
• Consider team-based care approach involving nephrology, primary care, and possibly endocrinology 2

Common Pitfalls to Avoid

1. Delaying nephrology referral in patients with eGFR <30 and complications
2. Continuing medications that worsen hyperkalemia without close monitoring
3. Setting overly strict glycemic targets in advanced CKD patients
4. Failing to educate patients about dietary potassium restrictions
5. Inadequate follow-up of laboratory values after medication changes

This comprehensive approach addresses the three critical issues - severe CKD, hyperkalemia, and poor glycemic control - while prioritizing patient safety and preventing further deterioration of kidney function.