What is the management plan for a patient with a Glomerular Filtration Rate (GFR) of 34?

Management of a Patient with GFR of 34 mL/min/1.73 m²

A patient with a GFR of 34 mL/min/1.73 m² has Stage 3b chronic kidney disease (CKD) and requires a comprehensive management plan focused on slowing disease progression, managing complications, and preparing for potential future renal replacement therapy. This condition represents a significant risk for both progression to end-stage kidney disease and cardiovascular events.

Immediate Management Priorities

Referral to Nephrology

• Referral to nephrology is strongly recommended for patients with GFR <30-45 mL/min/1.73 m² 1
• With GFR of 34, the patient is approaching the critical threshold of 30 mL/min/1.73 m² where specialist care becomes essential 2
• Nephrology consultation should occur within 3 months to establish a collaborative care plan 2

Blood Pressure Control

• Target blood pressure should be <130/80 mmHg using standardized office measurements 2
• First-line therapy should include an ACE inhibitor or ARB to both control blood pressure and reduce proteinuria 2, 3
• Losartan has been shown to reduce the risk of doubling of serum creatinine by 25% and ESRD by 29% in patients with proteinuria 3
• Advise sodium restriction (<2.0 g/day) to enhance blood pressure control 2
• Monitor for hyperkalemia when using ACE inhibitors or ARBs, especially at this level of kidney function 1

Proteinuria Assessment and Management

• Measure urinary albumin-to-creatinine ratio (UACR) to assess for proteinuria 1
• If proteinuria is present, maximize ACE inhibitor or ARB therapy to the highest tolerated dose 2
• Consider adding a diuretic if needed for enhanced blood pressure control and edema management 2

Metabolic Complications Management

Anemia Management

• Check hemoglobin levels; anemia is common at this stage of CKD 1
• If anemia is present (Hb <13 g/dL in men, <12 g/dL in women), evaluate iron status (ferritin, transferrin saturation) 1
• Consider iron supplementation if deficient; erythropoiesis-stimulating agents may be considered if severe anemia persists despite iron repletion 1

Mineral and Bone Disorder Management

• Monitor calcium, phosphorus, PTH, and vitamin D levels 1
• If iPTH >100 pg/mL, consider vitamin D supplementation 2
• Dietary phosphate restriction may be necessary if hyperphosphatemia develops 2

Metabolic Acidosis

• Check serum bicarbonate levels; treat if <22 mmol/L 2
• Oral sodium bicarbonate supplementation can help correct metabolic acidosis 1

Dyslipidemia Management

• Measure lipid profile (triglycerides, LDL, HDL, total cholesterol) 2
• Target LDL <100 mg/dL and non-HDL cholesterol <130 mg/dL 2
• Statin therapy is recommended for all adults ≥50 years with CKD stage 3b 1

Lifestyle Modifications

Dietary Recommendations

• Protein intake should be limited to 0.8 g/kg/day with emphasis on plant-based sources 2
• For patients with nephrotic-range proteinuria, protein intake may be adjusted to compensate for losses 2
• Sodium restriction to <2.0 g/day (<90 mmol/day) 2
• Target caloric intake of 30-35 kcal/kg/day 2

Physical Activity

• Recommend at least 150 minutes per week of moderate-intensity exercise 1
• If mobility is limited, consider referral to physical therapy 2

Smoking Cessation

• Strongly encourage smoking cessation as it accelerates CKD progression 1

Medication Review and Adjustments

Nephrotoxic Medications

• Avoid NSAIDs, aminoglycosides, and other potentially nephrotoxic medications 1
• Review all medications for appropriate dosing based on reduced GFR 1

Diabetes Management (if applicable)

• For diabetic patients, consider SGLT2 inhibitors which are recommended for patients with eGFR ≥20 mL/min/1.73 m² 1
• Metformin dose should be reduced to half when eGFR is 30-44 mL/min/1.73 m² 1
• Target HbA1c <7% for most patients 1

Monitoring and Follow-up

Laboratory Monitoring

• Monitor eGFR and albuminuria every 3-6 months 1
• Check electrolytes, particularly potassium, especially if on ACE inhibitors/ARBs 1
• Complete metabolic panel, CBC, and lipid profile should be checked regularly 1

Disease Progression Monitoring

• Watch for rapid decline in eGFR (>5 mL/min/1.73 m²/year), which would warrant more aggressive intervention 1
• Monitor for development of complications such as anemia, hyperkalemia, and metabolic acidosis 1

Future Planning

Education About Kidney Replacement Therapy

• Begin discussions about future renal replacement therapy options 2
• Preserve veins suitable for potential future vascular access 2
• Consider early transplant evaluation if the patient is a potential candidate 2

Common Pitfalls to Avoid

• Underestimating cardiovascular risk: CKD stage 3b carries a significantly elevated cardiovascular risk (20-30x higher than general population) 1
• Inadequate blood pressure control: Failing to achieve target BP is a common reason for accelerated CKD progression 2
• Medication errors: Failing to adjust medication dosages for reduced GFR can lead to adverse effects 1
• Late referral to nephrology: Delaying specialist involvement can result in missed opportunities to slow disease progression 2
• Overlooking modifiable lifestyle factors: Diet, exercise, and smoking cessation are crucial interventions 1

By implementing this comprehensive management plan, the goal is to slow CKD progression, manage complications effectively, and prepare for potential future renal replacement therapy if needed.