What is the management plan for a 48-year-old female with impaired renal function (eGFR 65)?

Management Plan for a 48-Year-Old Female with eGFR 65

The 48-year-old female with an eGFR of 65 mL/min/1.73m² has Stage 2 Chronic Kidney Disease (CKD) and requires a comprehensive management plan focused on preventing disease progression and reducing cardiovascular risk. This classification is based on the National Kidney Foundation guidelines that define CKD stages according to GFR levels 1.

Assessment of Kidney Function and Risk

• An eGFR of 65 mL/min/1.73m² indicates mild kidney damage with slightly decreased kidney function (Stage 2 CKD) 1
• At this stage, the patient has lost approximately 35-40% of normal kidney function, which is more than expected for age alone 1
• Risk assessment should include:
  • Urinary albumin-to-creatinine ratio (UACR) to assess for albuminuria 1, 2
  • Evaluation for underlying causes of kidney disease
  • Assessment of cardiovascular risk factors
  • Screening for complications of CKD

Monitoring Recommendations

• Monitor eGFR and albuminuria every 6-12 months 2
• Regular blood pressure monitoring, as hypertension accelerates kidney function decline 1
• Monitor serum electrolytes, particularly potassium, especially if starting ACE inhibitors or ARBs 1, 2
• Screen for anemia, metabolic acidosis, and mineral bone disorders if eGFR continues to decline 1, 2

Blood Pressure Management

• Target blood pressure should be <130/80 mmHg using standardized office measurements 2
• First-line therapy should include an ACE inhibitor (like lisinopril) or ARB (like losartan) to both control blood pressure and reduce proteinuria 2
• Start at low doses and titrate gradually with careful monitoring of renal function and serum potassium 1, 3
• If albuminuria 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 2

Medication Considerations

• Review all current medications for potential nephrotoxicity 2
• Avoid NSAIDs and other nephrotoxic medications 2
• Adjust medication dosages as needed based on current eGFR 3, 4
• For diabetic patients:
  • Metformin is safe at this eGFR level but should be monitored 1
  • Consider SGLT2 inhibitors if diabetic, as they appear to reduce risks of CKD progression 1

Lifestyle Modifications

• Protein intake should be approximately 0.8 g/kg body weight per day 1, 2
• Sodium restriction to <2.3 g/day to help control blood pressure 1, 2
• Regular physical activity (at least 150 minutes per week of moderate-intensity exercise) 2
• Weight management for overweight or obese patients 2
• Smoking cessation 2
• Plant-based "Mediterranean-style" diet 2

Cardiovascular Risk Management

• Statin therapy is recommended for adults ≥50 years with CKD 2
• Target LDL <100 mg/dL and non-HDL cholesterol <130 mg/dL 2
• For diabetic patients, achieve glycemic control (HbA1c <7%) 2

Follow-up and Referral

• At this stage (eGFR 65), primary care management is appropriate with nephrology consultation if:
  • Rapid decline in kidney function (>5 mL/min/1.73m² per year)
  • Significant albuminuria (UACR ≥300 mg/g)
  • Refractory hypertension
  • Uncertain etiology of kidney disease 2

Pitfalls and Caveats

• Age-related decline in renal function is normal (approximately 1% per year after age 30-40), but this patient's eGFR is lower than expected for her age 1
• Creatinine-based eGFR may overestimate kidney function in patients with low muscle mass 1
• When using ACE inhibitors or ARBs, monitor for hyperkalemia, especially if adding mineralocorticoid receptor antagonists 1
• Avoid the triple combination of ACE inhibitor, ARB, and mineralocorticoid receptor antagonist due to high risk of hyperkalemia 1
• Preserve peripheral veins for potential future vascular access if kidney disease progresses 2

By implementing this management plan, the goal is to slow progression of kidney disease, reduce cardiovascular risk, and improve long-term outcomes for this patient.