What management and investigations are recommended for a 60-year-old male patient with newly diagnosed Chronic Kidney Disease (CKD), hyperlipidemia, and a history of vaping?

Recommended Investigations for a 60-Year-Old Male with Early CKD and Hyperlipidemia

For a 60-year-old male with newly diagnosed CKD (eGFR 68 ml/min/1.73m²), hyperlipidemia, and vaping history, a statin should be initiated immediately along with comprehensive cardiovascular risk assessment and urinary albumin measurement to guide management.

Initial Diagnostic Workup

Kidney Function Assessment

• Urinary albumin-to-creatinine ratio (UACR) to assess for albuminuria and stratify CKD risk 1
• Complete urinalysis with microscopy to evaluate for hematuria, proteinuria, and cellular casts
• Renal ultrasound to assess kidney size, echogenicity, and rule out obstruction
• Monitoring of eGFR trend over time (every 6 months) 2

Cardiovascular Risk Assessment

• Lipid panel (already completed showing high cholesterol 265 mg/dl, high LDL 173 mg/dl, triglycerides 152 mg/dl)
• Fasting blood glucose and HbA1c to assess for diabetes
• 10-year cardiovascular risk calculation using a validated risk tool 1
• Blood pressure measurement using standardized technique with target <120 mmHg systolic 2
• Electrocardiogram to assess for left ventricular hypertrophy or ischemic changes

Management Recommendations

Lipid Management

• Initiate statin therapy immediately as the patient is >50 years with CKD 1
• Choose moderate to high-intensity statin to maximize LDL reduction 1
• Consider statin/ezetimibe combination if needed for target LDL reduction 1
• No need for routine follow-up lipid measurements after starting therapy unless to assess compliance 1

Blood Pressure Management

• Target systolic BP <120 mmHg using standardized measurement techniques 2
• If hypertensive, initiate ACE inhibitor or ARB, particularly if albuminuria is present 2
• Monitor potassium and creatinine 1-2 weeks after starting or increasing dose of ACE inhibitor/ARB 2

Smoking Cessation

• Provide strong recommendation for complete smoking/vaping cessation 1, 2
• Consider pharmacotherapy for smoking cessation with appropriate dose adjustments for CKD 3
• Refer to smoking cessation program if available 2

Lifestyle Modifications

• Sodium restriction to <2 g/day 2
• Moderate protein intake (0.8 g/kg/day) 2
• Diet high in vegetables, fruits, whole grains, fiber, legumes, and plant-based proteins 2
• Lower intake of processed meats, refined carbohydrates, and sweetened beverages 2
• Moderate-intensity physical activity for at least 150 minutes per week 2

Follow-up and Monitoring

Kidney Function Monitoring

• Monitor eGFR and albuminuria every 6 months 2
• More frequent monitoring (3-4 times per year) if albuminuria >300 mg/g is detected 2

Cardiovascular Risk Factor Monitoring

• Blood pressure assessment every 3-6 months 2
• Annual lipid profile not required after statin initiation unless to assess compliance 1

Nephrology Referral Criteria

• Consider nephrology referral if:
  • Albuminuria ≥300 mg/g is detected
  • Rapid decline in eGFR (>5 mL/min/1.73m²/year)
  • Difficulty managing hypertension
  • Persistent electrolyte abnormalities 2

Key Considerations and Pitfalls

• Do not delay statin initiation while waiting for additional test results, as the patient already meets criteria for statin therapy based on age >50 years with CKD 1
• Avoid using measured LDL-C as the sole marker for coronary risk in CKD patients, as the relationship between LDL-C and cardiovascular events is weaker in CKD 1
• Be aware that atherogenic dyslipidemia in CKD may include lower LDL-C levels but increased LDL particle concentration, small dense LDL, reduced HDL-C, and elevated triglycerides 1
• Monitor for potential drug interactions between statins and other medications the patient may be taking 2
• Recognize that smoking/vaping is a modifiable risk factor for both cardiovascular disease and CKD progression 3