What is the management plan for a 48-year-old female with impaired renal function (eGFR 65), elevated creatinine levels (1.06), and normal Blood Urea Nitrogen (BUN)?

Management of Mildly Impaired Renal Function in a 48-Year-Old Female

The patient's current renal function (eGFR 65 mL/min/1.73m², creatinine 1.06 mg/dL) requires monitoring but does not necessitate immediate nephrology referral or medication adjustments at this time.

Assessment of Current Renal Status

• eGFR of 65 mL/min/1.73m² indicates mild renal impairment (Stage 2 CKD)
• Creatinine has improved from 1.16 to 1.06 mg/dL (still slightly elevated)
• Normal BUN suggests absence of significant azotemia
• This presentation represents early kidney dysfunction that requires monitoring but not urgent intervention

Recommended Management Plan

Immediate Actions

1. Complete kidney function assessment

   • Obtain urine albumin-to-creatinine ratio (UACR) to assess for albuminuria 1, 2
   • Repeat serum creatinine and eGFR in 2-4 weeks to confirm stability 2

2. Identify potential causes and risk factors

   • Screen for diabetes with HbA1c and fasting glucose 1
   • Check blood pressure (target <130/80 mmHg for patients with CKD) 1
   • Review all medications for nephrotoxic agents (especially NSAIDs) 1, 3
   • Assess for supplement use that could affect creatinine levels 4, 5

Follow-up Plan

1. Monitoring frequency

   • If findings remain stable: Monitor kidney function every 6 months 1
   • If albuminuria present: Increase monitoring to every 3-4 months 1

2. Medication considerations

   • ACE inhibitors or ARBs may be beneficial if hypertension or albuminuria is present 1
   • When using ACE inhibitors/ARBs, monitor for:
     • Initial transient decrease in eGFR (up to 20% is acceptable) 1, 3
     • Hyperkalemia, especially if eGFR declines further 1, 3

3. Lifestyle modifications

   • Moderate protein intake (0.8 g/kg/day)
   • Sodium restriction (<2.3 g/day)
   • Regular physical activity
   • Weight management if overweight/obese

Nephrology Referral Criteria

Referral to nephrology is not indicated at present but would be warranted if:

• eGFR declines to <45 mL/min/1.73m² 1
• Significant albuminuria develops (UACR >300 mg/g) 1
• Rapid decline in kidney function (>5 mL/min/1.73m²/year) 2
• Development of resistant hypertension
• Persistent electrolyte abnormalities

Important Considerations and Pitfalls

• Creatinine limitations: Serum creatinine alone is an insufficient measure of kidney function as it's affected by muscle mass, age, sex, and diet 2, 6
• Supplement awareness: Creatine supplements can artificially elevate serum creatinine without actual kidney dysfunction 4, 5
• Medication caution: When using ACE inhibitors or ARBs:
  • Initial decline in eGFR up to 20% is expected and not concerning 1
  • Discontinuation is only necessary if creatinine rises >30% or hyperkalemia develops 1, 3
• Imaging consideration: Renal ultrasound should be considered if there's suspicion of structural kidney disease 1

This management approach focuses on confirming the stability of kidney function, identifying modifiable risk factors, and implementing appropriate monitoring to prevent progression of kidney disease while maintaining quality of life.