How to manage a patient with severe renal impairment?

Management of Severe Renal Impairment (GFR 14)

Immediate nephrology referral is essential for this patient with stage 5 chronic kidney disease (BUN 85, creatinine 4.58, GFR 14) to reduce morbidity and mortality and improve quality of life. 1

Initial Assessment and Management

Immediate Priorities

• Evaluate for uremic symptoms: nausea, vomiting, confusion, pruritus, fatigue
• Check for volume status: edema, hypertension, pulmonary congestion
• Assess electrolytes, particularly potassium and phosphorus
• Monitor acid-base status for metabolic acidosis
• Screen for anemia and mineral bone disorders

Medication Management

• Review all medications for renal dosing adjustments
• Discontinue nephrotoxic medications (NSAIDs, aminoglycosides, radiocontrast agents) 2
• Adjust doses of renally cleared medications according to GFR 2
• Use caution with diuretics and monitor electrolytes closely 2

Complication Management

Anemia Management

• Evaluate iron stores (ferritin, transferrin saturation) before initiating ESA therapy 3
• Consider erythropoietin therapy when hemoglobin <10 g/dL 3
• Administer supplemental iron when ferritin <100 mcg/L or transferrin saturation <20% 3
• Monitor hemoglobin weekly after initiation until stable, then monthly 3

Mineral Bone Disorder Management

• Monitor calcium, phosphorus, and PTH levels
• Consider calcitriol for secondary hyperparathyroidism 4
• Phosphate binders may be needed to control hyperphosphatemia
• Dietary phosphorus restriction is typically necessary

Blood Pressure Control

• Target BP <130/80 mmHg 2
• Use ACE inhibitors or ARBs with caution, monitoring for hyperkalemia 2
• Monitor for modest increases in serum creatinine (up to 30% may be acceptable) 2

Preparation for Renal Replacement Therapy

Dialysis Planning

• Discuss dialysis modality options (hemodialysis vs. peritoneal dialysis)
• Plan for vascular access creation if hemodialysis is chosen (ideally 3-6 months before anticipated need)
• Consider peritoneal dialysis catheter placement if PD is chosen
• Evaluate for potential transplantation eligibility

Timing of Dialysis Initiation

• Consider initiating dialysis when GFR falls below 15 ml/min (current patient is at GFR 14)
• Watch for signs/symptoms of uremia that don't respond to medical management
• Monitor for refractory hyperkalemia, volume overload, or acidosis
• Earlier initiation may be beneficial to prevent malnutrition and improve outcomes 5

Patient Education and Support

• Provide education about kidney disease progression and treatment options
• Discuss dietary modifications (sodium, potassium, phosphorus, protein)
• Address advance care planning and goals of care
• Engage multidisciplinary team (dietitian, social worker, pharmacist)

Pitfalls to Avoid

1. Delayed nephrology referral - Late referral is associated with increased morbidity and mortality 6
2. Inadequate vascular access planning - Temporary catheters increase infection risk
3. Overlooking conservative management - For some patients, conservative non-dialytic care may be appropriate 1
4. Medication errors - Failure to adjust medication dosages can lead to toxicity
5. Ignoring patient preferences - Treatment decisions should incorporate patient values and goals 1

The management of this patient with severe renal impairment requires a collaborative approach between primary care and nephrology, with careful attention to complications of CKD and preparation for renal replacement therapy if appropriate for the patient's clinical situation and goals.