What is the management plan for a patient with impaired renal function, specifically a glomerular filtration rate (GFR) of 11.5?

Management of a Patient with GFR 11.5 mL/min/1.73m²

A patient with a GFR of 11.5 mL/min/1.73m² should be promptly referred to a nephrologist for evaluation and preparation for renal replacement therapy, as this represents stage 5 chronic kidney disease (kidney failure). 1

Immediate Management Priorities

Nephrology Referral

• Immediate referral to nephrology is mandatory as the GFR is <15 mL/min/1.73m², which defines stage 5 CKD (kidney failure) 1
• The patient requires urgent evaluation for renal replacement therapy planning 1

Renal Replacement Therapy Planning

• Begin discussions about renal replacement therapy options:
  • Hemodialysis
  • Peritoneal dialysis
  • Kidney transplantation (if eligible)
• Evaluate for potential transplantation if the patient is willing and has no contraindications 1
• If hemodialysis is planned, arrange for vascular access creation (preferably arteriovenous fistula) 1
• If peritoneal dialysis is planned, arrange for catheter placement 1

Medical Management

Blood Pressure Control

• Target blood pressure <130/80 mmHg 1, 2
• Continue ACE inhibitors or ARBs if already prescribed, with careful monitoring of potassium and creatinine 1
• Do not discontinue renin-angiotensin system blockade for increases in serum creatinine (≤30%) in the absence of volume depletion 1

Electrolyte and Metabolic Management

• Monitor serum potassium, phosphorus, calcium, and bicarbonate levels frequently (every 1-2 weeks) 1, 2
• Treat hyperkalemia if present:
  • Dietary potassium restriction
  • Potassium-binding agents if needed
• Treat hyperphosphatemia:
  • Dietary phosphate restriction
  • Phosphate binders
• Treat metabolic acidosis if bicarbonate <22 mmol/L 2

Anemia Management

• Check hemoglobin level; if <10 g/dL, evaluate iron stores (ferritin, transferrin saturation) 3
• Initiate erythropoietin therapy if hemoglobin <10 g/dL after ensuring adequate iron stores 3
• Target hemoglobin: 10-11 g/dL (avoid exceeding 11 g/dL due to cardiovascular risks) 3
• Administer supplemental iron if ferritin <100 mcg/L or transferrin saturation <20% 3

Nutritional Management

• Dietary protein intake should be 0.8 g/kg body weight per day 1
• For patients on dialysis, higher protein intake may be needed to prevent protein-energy wasting 1
• Sodium restriction to <2.0 g/day 2
• Monitor nutritional status with regular body weight and serum albumin measurements 1
• If signs of malnutrition are present (unintentional weight loss >5% or albumin decrease >0.3 g/dL), initiate nutritional intervention 1

Cardiovascular Risk Management

• Statin therapy for cardiovascular risk reduction 1, 2
• Target LDL <100 mg/dL and non-HDL cholesterol <130 mg/dL 1
• Encourage smoking cessation if applicable 2
• Recommend regular physical activity as tolerated 2

Monitoring and Follow-up

Laboratory Monitoring

• Weekly monitoring of:
  • Serum creatinine and eGFR
  • Electrolytes (especially potassium)
  • Calcium and phosphorus
• Monthly monitoring of:
  • Complete blood count
  • Albumin
  • PTH and vitamin D levels
  • Urinary protein excretion

Clinical Monitoring

• Assess for uremic symptoms (nausea, vomiting, pruritus, encephalopathy)
• Monitor fluid status (edema, weight changes, blood pressure)
• Evaluate for signs of mineral bone disorder
• Monitor nutritional status

Indications for Immediate Dialysis Initiation

Despite the low GFR, the decision to start dialysis should not be based solely on the GFR value 1. Consider immediate initiation of dialysis for any of the following:

• Uremic symptoms (encephalopathy, pericarditis, nausea/vomiting)
• Refractory hyperkalemia (>6.5 mmol/L despite medical management)
• Volume overload unresponsive to diuretics
• Metabolic acidosis unresponsive to medical therapy
• Malnutrition despite nutritional intervention 1

Common Pitfalls to Avoid

• Delaying nephrology referral - this can lead to unplanned emergency dialysis starts and higher morbidity
• Focusing solely on GFR without considering clinical symptoms
• Discontinuing ACE inhibitors/ARBs based on mild increases in creatinine
• Targeting hemoglobin >11 g/dL with erythropoietin therapy (increases cardiovascular risks)
• Inadequate preparation for renal replacement therapy (lack of vascular access planning)
• Neglecting nutritional status assessment and intervention

This management approach prioritizes timely preparation for renal replacement therapy while optimizing medical management to minimize complications and improve quality of life during the transition to dialysis or transplantation.