What is the most appropriate recommendation for a 42-year-old female with chronic kidney disease (CKD), epilepsy, anxiety, polysubstance use disorder, hypertension, and gout?

Dietary Sodium Restriction for CKD Management

Restricting sodium intake to less than 2 g per day is the most appropriate recommendation for this patient with CKD and severely increased albuminuria, based on the 2024 KDIGO clinical practice guideline for CKD management. 1

Rationale for Sodium Restriction

The 2024 KDIGO guideline specifically recommends sodium intake be <2 g per day (or <5 g sodium chloride per day) in people with CKD (Recommendation 3.3.2.1) 1. This recommendation is particularly important for this 42-year-old female patient who has:

• CKD with eGFR of 34 mL/min/1.73 m² (Stage 3b)
• Severely increased albuminuria (urine albumin-creatinine ratio > 300 mg/g)
• Hypertension
• Obesity (BMI 52.1 kg/m²)

Sodium restriction is a cornerstone of CKD management because it:

• Enhances the antiproteinuric effect of RAS inhibitors (irbesartan in this case)
• Improves blood pressure control
• Reduces cardiovascular risk
• May slow CKD progression

Evaluation of Other Options

1. Starting bupropion for smoking cessation: While smoking cessation is important for patients with CKD, the sodium restriction recommendation directly addresses the worsening eGFR and albuminuria, which is the primary concern expressed by the primary care provider.

2. Vigorous physical activity for 100 minutes per week: This recommendation is inappropriate for this patient with severe obesity (BMI 52.1 kg/m²). While physical activity is beneficial, the KDIGO guidelines do not specify vigorous activity for 100 minutes weekly, and such intensity could pose risks given her multiple comorbidities.

3. Diet emphasizing animal-based foods: This directly contradicts the KDIGO guideline Practice Point 3.3.1, which advises people with CKD to adopt "healthy and diverse diets with a higher consumption of plant-based foods compared to animal-based foods" 1.

Comprehensive Management Approach

Dietary Recommendations

• Sodium restriction: <2 g sodium per day 1
• Protein intake: Maintain at 0.8 g/kg body weight/day 1
• Diet composition: Higher consumption of plant-based foods compared to animal-based foods 1
• Processed foods: Lower consumption of ultraprocessed foods 1

Medication Optimization

• RAS inhibitor: Continue irbesartan but consider titrating to maximum tolerated dose (up to 300 mg daily) for optimal antiproteinuric effect 2
• Monitor closely: Check serum creatinine, potassium, and blood pressure within 2-4 weeks of any dose adjustment 1

Lifestyle Modifications

• Weight management: Encourage weight loss for this patient with obesity (BMI 52.1 kg/m²) 1
• Physical activity: Encourage moderate physical activity appropriate to her cardiovascular and physical tolerance 3
• Smoking cessation: Address tobacco use disorder, but sodium restriction takes priority for kidney protection 3

Implementation Strategies

1. Referral to renal dietitian: The KDIGO guideline recommends using renal dietitians to educate people with CKD about dietary adaptations 1

2. Practical sodium reduction tips:

   • Avoid adding salt during cooking or at the table
   • Choose fresh foods over processed foods
   • Read food labels for sodium content
   • Use herbs and spices instead of salt for flavoring

3. Regular monitoring: Follow kidney function, albuminuria, blood pressure, and electrolytes to assess response to dietary changes

Potential Pitfalls and Caveats

• Adherence challenges: Sodium restriction can be difficult to maintain; provide practical strategies and ongoing support
• Medication interactions: Monitor for hyperkalemia with combined sodium restriction and RAS inhibitor therapy
• Nutritional adequacy: Ensure dietary changes maintain adequate nutrition despite restrictions
• Individualization: While sodium restriction is recommended for most CKD patients, it's not appropriate for those with sodium-wasting nephropathy 1

By implementing sodium restriction as recommended by the 2024 KDIGO guidelines, we can address this patient's worsening kidney function and albuminuria while supporting her overall health management.