Management of a 68-Year-Old Woman with GFR of 58
A 68-year-old woman with a GFR of 58 mL/min/1.73 m² has Stage 3a chronic kidney disease (CKD) and requires comprehensive management focused on slowing disease progression, monitoring for complications, and reducing cardiovascular risk.
Classification and Staging
According to the Kidney Disease Outcomes Quality Initiative (KDOQI) and Kidney Disease: Improving Global Outcomes (KDIGO) guidelines, this patient falls into Stage 3a CKD:
| Stage | Description | GFR (mL/min/1.73 m²) |
|---|---|---|
| 3a | Mild to moderate decrease in GFR | 45-59 |
Management Recommendations
Blood Pressure Control
- Target systolic blood pressure <120 mmHg using standardized office BP measurement 1
- Use ACE inhibitors or ARBs as first-line therapy for both hypertension and proteinuria
- Uptitrate to maximally tolerated or allowed dose
- Monitor labs frequently when on ACEi or ARB
- Counsel patient to hold ACEi/ARB and diuretics during periods of potential volume depletion (illness, diarrhea, etc.) 1
Proteinuria Management
- Assess for proteinuria using albumin-creatinine ratio
- If proteinuria present, treat with ACEi or ARB even if normotensive
- Consider using potassium-wasting diuretics and/or potassium-binding agents if hyperkalemia develops to allow continued use of RAS blockers 1
Lifestyle Modifications
- Restrict dietary sodium to <2.0 g/day (<90 mmol/day)
- For patients with GFR <60 ml/min/1.73 m² and proteinuria:
- Limit protein intake to 0.8 g/kg/day
- Target caloric intake of 30-35 kcal/kg/day
- Emphasize plant-based protein sources 1
- Normalize weight
- Stop smoking
- Exercise regularly 1
Cardiovascular Risk Management
- Assess cardiovascular risk factors
- Consider statin therapy, especially if other cardiovascular risk factors present (hypertension, diabetes) 1
- Treat metabolic acidosis if serum bicarbonate <22 mmol/l 1
Monitoring Schedule
- Monitor GFR and albuminuria every 6-12 months 2
- Screen for anemia, as prevalence increases when GFR falls below 60 ml/min/1.73 m² 2
- Evaluate for mineral bone disease (calcium, phosphate, vitamin D)
- Monitor for metabolic acidosis
Important Considerations
Age-Related Decline vs. Disease
While GFR naturally declines with age (approximately 1% per year beyond age 30-40), a GFR of 58 in a 68-year-old woman should not be dismissed as normal aging 1. This level of kidney function:
- Represents a moderate decrease in GFR
- Is associated with increased risk for cardiovascular events
- Requires appropriate monitoring and management 2
Common Pitfalls to Avoid
Relying solely on serum creatinine: Serum creatinine alone can underestimate renal insufficiency in the elderly. GFR must decrease by at least 40% before serum creatinine significantly increases 1.
Failure to adjust medications: Many medications require dose adjustment with reduced GFR, especially those with renal clearance.
Overlooking cardiovascular risk: Patients with Stage 3a CKD have significantly increased cardiovascular risk compared to those with normal kidney function 2.
Inadequate monitoring for complications: As GFR declines below 60 ml/min/1.73 m², risk for anemia, bone disease, and metabolic abnormalities increases 1.
Nephrotoxic medications: Avoid nephrotoxic agents when possible, including NSAIDs and certain antibiotics.
By implementing these evidence-based recommendations, the goal is to slow progression of kidney disease, reduce cardiovascular risk, and maintain quality of life for this 68-year-old woman with Stage 3a CKD.