How to manage a patient with impaired renal function and eGFR of 58?

Management of a Patient with eGFR of 58 mL/min/1.73 m²

A patient with an eGFR 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 Initial Assessment

• This patient's creatinine of 1.49 mg/dL and eGFR of 58 mL/min/1.73 m² indicates Stage 3a CKD (eGFR 45-59 mL/min/1.73 m²) 1
• At this stage, the risk of progression to more advanced CKD and cardiovascular complications is increased
• While nephrology referral is not mandatory at this stage, consider referral if there are additional risk factors 2, 1

Blood Pressure Management

• Target blood pressure should be <130/80 mmHg using standardized office measurements 1
• First-line therapy should include an ACE inhibitor or ARB to both control blood pressure and reduce proteinuria 1
• Monitor renal function and potassium levels within 1-2 weeks of starting ACE inhibitor/ARB therapy 3
• Advise sodium restriction (<2.0 g/day) to enhance blood pressure control 2

Proteinuria Assessment and Management

• Check urine albumin-to-creatinine ratio (UACR) to assess for albuminuria 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

Cardiovascular Risk Reduction

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

Metabolic Monitoring

• Check serum bicarbonate levels; treat if <22 mmol/L 1
• Monitor serum calcium, phosphate, PTH, and vitamin D levels 1
• If iPTH >100 pg/mL, consider vitamin D supplementation 1
• Screen for anemia with hemoglobin measurement 1

Lifestyle Modifications

• Protein intake should be limited to 0.8 g/kg/day with emphasis on plant-based sources 1
• Recommend physical activity of at least 150 minutes per week of moderate-intensity exercise 1
• Emphasize smoking cessation if applicable 1
• Weight management for overweight or obese patients 1

Monitoring and Follow-up

• Monitor eGFR and albuminuria every 6 months 1
• Monitor electrolytes, particularly potassium, especially if on ACE inhibitors/ARBs 3
• Complete metabolic panel, including electrolytes, BUN, creatinine 1
• Increase monitoring frequency if there are signs of rapid progression (decline in eGFR >5 mL/min/1.73 m² per year) 1

Medication Review and Adjustments

• Review all medications for potential nephrotoxicity 2
• Avoid NSAIDs and other nephrotoxic medications 1
• Adjust medication dosages as needed based on current eGFR 2

Indications for Nephrology Referral

• Rapid decline in eGFR (>5 mL/min/1.73 m² per year) 1
• Significant albuminuria (UACR ≥300 mg/g) 1
• Refractory hypertension 1
• Uncertain etiology of kidney disease 1
• If eGFR declines to <45 mL/min/1.73 m² 1

Patient Education

• Educate about CKD, its progression, and the importance of adherence to treatment 1
• Discuss the relationship between CKD and cardiovascular disease 1
• Emphasize the importance of regular monitoring and follow-up 1

Clinical Pearls and Pitfalls

• Early diagnosis and management of CKD are associated with improved outcomes and slower disease progression 4
• Recorded diagnosis of CKD is associated with better management practices and attenuated eGFR decline 4
• Be aware that certain supplements like creatine can artificially affect serum creatinine levels and eGFR calculations 5
• eGFR alone does not capture all aspects of kidney function; consider clinical context and urine analysis 6
• Avoid delaying diagnosis, as each year of delay is associated with a 40% increased risk of progression to stage 4/5 CKD 4