What is the significance of a steady decline in estimated Glomerular Filtration Rate (eGFR) in a patient with a history of hysterectomy complicated by transected ureter with reimplantation?

Significance of Declining eGFR Following Hysterectomy with Ureter Injury

The steady decline in eGFR from 98 to 55 over approximately 5 months following a hysterectomy complicated by transected ureter with reimplantation strongly suggests post-surgical chronic kidney disease that requires immediate nephrology referral and intervention. 1, 2

Understanding the eGFR Decline Pattern

The patient's eGFR values show a concerning pattern:

• 03/06/25: eGFR 98 mL/min/1.73m²
• 04/20/25: eGFR 78 mL/min/1.73m² (20-point drop in ~6 weeks)
• 08/22/25: eGFR 55 mL/min/1.73m² (23-point drop in ~4 months)

This represents a decline of approximately 43 mL/min/1.73m² over 5.5 months, which calculates to an annual decline rate of approximately 94 mL/min/1.73m²/year. This far exceeds the KDIGO threshold for "rapid progression" defined as >5 mL/min/1.73m²/year 1.

Clinical Significance and Risk Assessment

1. Surgical Complication Impact:

   • The transected ureter with reimplantation during hysterectomy is the most likely cause of this decline 2
   • Ureter injury can lead to ureteral stricture, hydronephrosis, and progressive kidney damage

2. CKD Staging and Risk:

   • Current eGFR of 55 places the patient in CKD Stage 3a (eGFR 45-59) 2
   • This rapid decline pattern is associated with:
     • 1.89-fold increased risk of all-cause mortality 1
     • 5.11-fold increased risk of end-stage renal disease 1
     • Increased cardiovascular risk 3

3. Rate of Decline Concerns:

   • Normal annual eGFR decline in CKD populations ranges from 1-4 mL/min/1.73m²/year 1
   • This patient's decline rate is approximately 20-25 times faster than expected

Recommended Management Approach

1. Immediate Nephrology Referral:

   • eGFR <60 with rapid decline warrants specialist evaluation 2
   • Nephrologist should assess for reversible causes and develop management plan

2. Urological Re-evaluation:

   • Assess for post-surgical complications:
     • Ureteral stricture at reimplantation site
     • Hydronephrosis
     • Obstruction
   • Consider renal ultrasound and possible retrograde pyelogram

3. Laboratory Workup:

   • Comprehensive metabolic panel
   • Urinalysis with microscopy
   • Urine protein-to-creatinine ratio
   • Assess for albuminuria which would indicate kidney damage 1

4. Blood Pressure Management:

   • Target <130/80 mmHg
   • Consider ACE inhibitor or ARB therapy if albuminuria present 2

5. Medication Review:

   • Discontinue any potentially nephrotoxic medications
   • Adjust dosages of medications cleared by kidneys

Monitoring and Follow-up

1. Short-term Monitoring:

   • Check eGFR and creatinine every 2-4 weeks until stabilized
   • Monitor for electrolyte abnormalities, especially potassium

2. Long-term Surveillance:

   • Once stabilized, monitor eGFR every 3-6 months
   • Regular assessment of cardiovascular risk factors

Prognosis and Patient Education

The patient should understand that:

• This decline rate is abnormal and concerning
• Without intervention, continued decline could lead to kidney failure
• Early intervention may stabilize kidney function
• The goal is to slow progression and prevent complications

Common Pitfalls to Avoid

1. Attributing decline to "normal aging" - This rate of decline is pathological, not age-related 2

2. Focusing only on absolute eGFR values - The rapid rate of decline is more concerning than the current value 1, 3

3. Delaying nephrology referral - Early specialist involvement improves outcomes 2

4. Missing reversible causes - Post-surgical complications like stricture or obstruction may be correctable if identified early

5. Inadequate blood pressure control - Hypertension accelerates kidney function decline 2

This patient requires urgent evaluation to identify the cause of rapid eGFR decline and implement strategies to preserve remaining kidney function.