What is the management plan for an outpatient with impaired renal function, specifically an estimated Glomerular Filtration Rate (EGFR) below 60?

Management of Outpatient with eGFR Below 60 mL/min/1.73 m²

When a patient presents with an eGFR below 60 mL/min/1.73 m², they should be referred to a physician experienced in the care of diabetic renal disease for comprehensive management of chronic kidney disease (CKD). 1

CKD Classification and Initial Assessment

• Patient with eGFR <60 mL/min/1.73 m² has CKD Stage 3 or worse:

  • Stage 3: eGFR 30-59 mL/min/1.73 m²
  • Stage 4: eGFR 15-29 mL/min/1.73 m²
  • Stage 5: eGFR <15 mL/min/1.73 m² 1

• Initial assessment should include:

  1. Evaluation of albuminuria (spot urine albumin-to-creatinine ratio)
  2. Measurement of serum electrolytes, particularly potassium
  3. Assessment for CKD complications (anemia, metabolic acidosis, mineral disorders) 1

Management Priorities

1. Blood Pressure Control

• Target blood pressure <140/90 mmHg 1
• First-line agents:
  • ACE inhibitors or ARBs are recommended, particularly in patients with albuminuria 1
  • Monitor serum creatinine and potassium after initiation
  • May need dose adjustment based on eGFR level 1

2. Glycemic Control (for Diabetic Patients)

• Optimize glucose control to reduce risk of CKD progression 1
• Medication adjustments based on eGFR:
  • Metformin:
    • eGFR 45-59 mL/min/1.73 m²: Consider dose reduction 2
    • eGFR 30-44 mL/min/1.73 m²: Reduce dose by half 2
    • eGFR <30 mL/min/1.73 m²: Discontinue 2
  • SGLT2 inhibitors:
    • Consider for patients with eGFR ≥45 mL/min/1.73 m² 1
    • Some may be used at lower eGFR levels per recent guidelines 1
  • GLP-1 receptor agonists:
    • Most can be used without dose adjustment at eGFR >30 mL/min/1.73 m² 1
    • Preferred agents with documented cardiovascular benefits 1

3. Protein Restriction

• Restrict protein intake to 0.8 g/kg body weight/day (approximately 10% of daily calories) for patients with nephropathy 1

4. Management of Complications

Monitor and treat CKD-related complications that typically emerge as eGFR declines:

• Hyperparathyroidism (begins at eGFR ~50 mL/min/1.73 m²) 3
• Anemia (begins at eGFR ~44 mL/min/1.73 m²) 3
• Metabolic acidosis (begins at eGFR ~40 mL/min/1.73 m²) 3
• Hyperkalemia (begins at eGFR ~39 mL/min/1.73 m²) 3
• Hyperphosphatemia (begins at eGFR ~37 mL/min/1.73 m²) 3

5. Medication Review and Adjustment

• Avoid nephrotoxins (e.g., NSAIDs) 4
• Review all medications and adjust dosages based on current eGFR 1
• Temporarily discontinue certain medications during acute illness or procedures with risk of AKI 1

Monitoring and Follow-up

• Frequency of monitoring should increase as eGFR declines 5
• For eGFR 30-59 mL/min/1.73 m²:
  • Monitor eGFR, electrolytes, and urine albumin-to-creatinine ratio every 6 months
  • Screen for complications of CKD (anemia, metabolic bone disease) 1
• For eGFR <30 mL/min/1.73 m²:
  • Monitor every 3 months
  • Mandatory referral to nephrology 5, 4

Nephrology Referral Criteria

• Immediate referral when eGFR <30 mL/min/1.73 m² 1, 5
• Consider referral for:
  • Difficult management issues (resistant hypertension, electrolyte disturbances)
  • Rapid decline in eGFR (>3 mL/min/1.73 m² per year) 6
  • Significant albuminuria (>300 mg/g creatinine) 1
  • Uncertainty about etiology of kidney disease 1

Common Pitfalls to Avoid

1. Delayed nephrology referral - Associated with increased mortality after dialysis initiation 5
2. Overlooking eGFR fluctuations - Single measurements may not reflect true kidney function; long-term trends are more reliable 6
3. Failure to adjust medications - Not modifying doses of renally cleared drugs can lead to adverse effects 1
4. Continued use of nephrotoxic agents - NSAIDs and certain other medications can accelerate kidney function decline 4
5. Inadequate monitoring of electrolytes - Particularly potassium when using ACE inhibitors or ARBs 1

By following this structured approach to managing patients with eGFR <60 mL/min/1.73 m², you can slow CKD progression, prevent complications, and improve patient outcomes.