How to manage Impaired renal function with a GFR of 19?

Management of Impaired Renal Function with GFR of 19

For a patient with a GFR of 19 mL/min/1.73m², renal replacement therapy should be initiated to preserve remaining kidney function and prevent complications of end-stage renal disease. 1

Blood Pressure Management

Blood pressure control is critical for preserving remaining kidney function:

• Target systolic blood pressure should be <120 mmHg using standardized office BP measurement 1
• First-line therapy should include an ACE inhibitor or ARB titrated to maximally tolerated dose 1, 2
• Monitor serum creatinine and potassium frequently after initiation or dose adjustment of ACEi/ARB 1
• Do not discontinue ACEi/ARB with modest and stable increases in serum creatinine (up to 30%) 1
• Stop ACEi/ARB if kidney function continues to worsen or if refractory hyperkalemia develops 1

Medication Considerations with GFR of 19

• Losartan can be used in patients with renal impairment without dose adjustment unless the patient is volume depleted 3
• Lisinopril elimination is decreased with GFR <30 mL/min, requiring careful dosing and monitoring 4
• Consider using potassium-wasting diuretics and/or potassium-binding agents to manage hyperkalemia while maintaining RAS blockade 1

Proteinuria Management

If proteinuria is present:

• Target proteinuria reduction with maximum tolerated doses of ACEi/ARB 2
• For persistent proteinuria despite treatment, consider intensifying dietary sodium restriction 1
• Consider mineralocorticoid receptor antagonists in refractory cases, with careful monitoring for hyperkalemia 1

Edema Management

For patients with edema:

• Use loop diuretics as first-line therapy 1
• Twice daily dosing is preferred over once daily dosing 1
• Consider longer-acting loop diuretics (bumetanide or torsemide) if furosemide is ineffective 1
• For resistant edema, combine loop diuretics with thiazide diuretics for synergistic effect 1
• Monitor for adverse effects including hypokalemia, hyponatremia, and worsening GFR 1

Dietary Modifications

• Restrict dietary sodium to <2.0 g/day (<90 mmol/day) 1, 2
• Protein intake should be approximately 0.8 g/kg/day 1
• Normalize weight if overweight or obese 1
• Consider plant-based protein sources rather than animal proteins 2

Metabolic Complications Management

• Treat metabolic acidosis if serum bicarbonate <22 mmol/L 1
• Consider statin therapy for hyperlipidemia, particularly in patients with other cardiovascular risk factors 1
• Monitor nutritional status regularly by measuring body weight and serum albumin 1

Preparation for Renal Replacement Therapy

With a GFR of 19 mL/min/1.73m², the patient is at stage 4 chronic kidney disease and approaching stage 5:

• Initiate discussion about modality of renal replacement therapy 1
• If hemodialysis is planned, preserve veins suitable for vascular access placement 1
• If transplantation is an option, refer for transplant evaluation 1
• Consider initiating renal replacement therapy, especially if there is evidence of malnutrition that does not respond to nutritional intervention 1

Monitoring and Follow-up

• Check blood pressure at every clinic visit, at least every three months 1
• Monitor serum creatinine, potassium, and proteinuria every 1-2 weeks after initiation or dose increase of ACEi/ARB, then every 3 months 2
• Monitor nutritional status by measuring body weight and serum albumin every three months 1
• Screen for and manage dyslipidemias with measurements of triglycerides, LDL, HDL, and total cholesterol 1

Common Pitfalls to Avoid

• Discontinuing ACEi/ARB prematurely due to modest increases in serum creatinine 5
• Inadequate management of hyperkalemia leading to unnecessary discontinuation of renoprotective medications 1
• Failing to counsel patients to hold ACEi/ARB and diuretics during periods of volume depletion (sick days) 1
• Overlooking the need for renal replacement therapy planning at this advanced stage of CKD 1
• Ignoring cardiovascular risk management, which is elevated in patients with severe CKD 2

By implementing this comprehensive approach to managing impaired renal function with a GFR of 19, you can help slow disease progression, manage complications, and prepare for the eventual need for renal replacement therapy.