What is the management for an eGFR of 35 mL/min?

Management of eGFR 35 mL/min/1.73 m²

For a patient with an eGFR of 35 mL/min/1.73 m², comprehensive management should include SGLT2 inhibitors, RAS blockade, metformin dose adjustment, and regular monitoring of kidney function. 1

Classification and Risk Assessment

• This eGFR value corresponds to CKD stage 3b (eGFR 30-44 mL/min/1.73 m²)
• Represents moderate to severe reduction in kidney function
• Associated with increased risk of:
  • CKD progression
  • Cardiovascular events
  • Mortality

Medication Management

First-line Medications

1. SGLT2 Inhibitors

   • Strongly recommended for patients with eGFR ≥20 mL/min/1.73 m² 1
   • Benefits:
     • Slow CKD progression
     • Reduce heart failure risk
     • Reduce cardiovascular events
     • Effects independent of glycemic control
   • Monitoring:
     • Initial "eGFR dip" of 3-5 mL/min/1.73 m² is expected and not a reason to discontinue 1
     • Continue even if eGFR falls below initial threshold (as long as remains ≥20 mL/min/1.73 m²) 1

2. RAS Blockade (ACEi or ARB)

   • Continue if already on therapy 1
   • Initiate if patient has:
     • Albuminuria (especially if >300 mg/g creatinine)
     • Hypertension
     • Heart failure with reduced ejection fraction
   • Dosing:
     • Titrate to highest tolerated dose 1
     • Continue even when eGFR falls below 30 mL/min/1.73 m² 1
   • Monitoring:
     • Check serum creatinine and potassium 2-4 weeks after initiation or dose change 1
     • Continue unless creatinine rises >30% within 4 weeks 1

Metformin Management

• Dose adjustment required at this eGFR level 1
• Do not initiate if eGFR <45 mL/min/1.73 m² 1
• If already on metformin:
  • Reassess benefits and risks
  • Consider dose reduction
  • Monitor eGFR regularly
  • Temporarily discontinue during acute illness or procedures with contrast media 1

Additional Medications to Consider

1. GLP-1 Receptor Agonists

   • Consider for cardiovascular risk reduction 1
   • Prioritize agents with documented cardiovascular benefits 1
   • Preferred option if eGFR declines below 20 mL/min/1.73 m² 1

2. Nonsteroidal Mineralocorticoid Receptor Antagonist (ns-MRA)

   • Consider for patients with:
     • Type 2 diabetes
     • eGFR >25 mL/min/1.73 m²
     • Normal potassium
     • Persistent albuminuria despite RAS inhibition 1
   • Monitor potassium regularly after initiation 1

Monitoring and Follow-up

1. Regular eGFR and Albuminuria Assessment

   • Monitor at least twice yearly 1
   • More frequent monitoring if:
     • Starting new medications (especially SGLT2i, ACEi, ARB)
     • Rapid progression
     • Acute illness

2. Blood Pressure Management

   • Target: <130/80 mmHg 1
   • Consider lower targets for patients with significant albuminuria (≥300 mg/g) 1

3. Glycemic Control

   • Individualize HbA1c targets:
     • Generally aim for <7.0% in younger patients with fewer comorbidities
     • Consider less stringent targets (7.0-8.0%) for elderly patients or those with multiple comorbidities 1

4. Lipid Management

   • Statin therapy recommended for all adults with CKD
   • Consider dose reduction for eGFR <60 mL/min/1.73 m² 1

5. Nephrology Referral

   • Recommended at this eGFR level (35 mL/min/1.73 m²) 1
   • Benefits of early referral:
     • Coordinated care to slow progression
     • Improved management of complications
     • Preparation for potential kidney replacement therapy

Common Pitfalls to Avoid

1. Discontinuing beneficial medications prematurely

   • Don't stop ACEi/ARB solely based on eGFR <30 mL/min/1.73 m² 1
   • Don't discontinue SGLT2i due to initial eGFR dip 1

2. Failure to implement "sick day rules"

   • Advise temporary discontinuation of metformin, SGLT2i, ACEi/ARB, and NSAIDs during:
     • Acute illness
     • Dehydration
     • Perioperative periods
     • Contrast procedures 1

3. Missing cardiovascular risk reduction opportunities

   • CKD at this stage significantly increases cardiovascular risk
   • Comprehensive approach must address both kidney and cardiovascular protection 1

4. Inadequate monitoring of medication effects

   • Failure to monitor serum creatinine and potassium after starting or adjusting RAS blockade
   • Not recognizing expected vs. pathologic changes in kidney function

By implementing this comprehensive management approach, the goal is to slow CKD progression, reduce cardiovascular risk, and improve overall outcomes for patients with an eGFR of 35 mL/min/1.73 m².