What is the management plan for a patient with a GFR of 25 indicating impaired renal function?

Management Plan for a Patient with GFR of 25

A patient with a GFR of 25 mL/min/1.73m² requires comprehensive monitoring and management of complications of chronic kidney disease (CKD), including blood pressure control with ACE inhibitors or ARBs, metabolic abnormality correction, anemia management, and preparation for potential renal replacement therapy. 1, 2

Blood Pressure Management

• Monitor blood pressure at every clinic visit, which should occur at least every 3 months 1
• Target blood pressure: <130/80 mmHg 1
• First-line therapy: ACE inhibitor or ARB 1
  • Start at low doses (e.g., lisinopril 2.5-5mg daily) 3
  • Monitor serum creatinine and potassium within 7-14 days after initiation 2
  • A rise in creatinine up to 30% is acceptable 2
• Avoid combining ACE inhibitors with ARBs due to increased risk of hyperkalemia 2
• Avoid NSAIDs which can worsen renal function 2
• Use caution with diuretics to avoid volume depletion 2

Metabolic Abnormalities Management

Acidosis

• Monitor serum bicarbonate concentration at least every 3 months 1
• Correct chronic metabolic acidosis to maintain serum bicarbonate ≥22 mmol/L 1

Calcium and Phosphorus

• Measure serum calcium and phosphorus at least every 3 months 1
• Measure iPTH at least once, and every 3 months if calcium/phosphorus levels are abnormal 1
• If phosphorus ≥4.5 mg/dL or iPTH ≥100 pg/mL:
  • Prescribe low phosphorus diet (800-1000 mg/day) for one month 1
  • If phosphorus remains ≥4.5 mg/dL, start phosphate binders 1
  • Monitor iPTH every 3 months regardless of phosphorus control 1

Vitamin D Management

• If iPTH ≥100 pg/mL, measure 25(OH) vitamin D 1
• If 25(OH) vitamin D <30 ng/mL, administer vitamin D2 50,000 units orally monthly for 6 months 1

Hypocalcemia

• If corrected serum calcium is <8.5 mg/dL after addressing phosphorus issues, provide elemental calcium 1g/day between meals or at bedtime 1

Anemia Management

• Check hemoglobin at least every 3 months 1
• If hemoglobin <12 g/dL (women) or <13 g/dL (men), perform complete anemia workup including iron studies 1
• Treat iron deficiency if identified 1
• If anemia persists despite iron therapy, initiate erythropoietin or analogue 1
• Monitor blood pressure with each erythropoietin dose 1

Nutritional Management

• Monitor nutritional status by measuring body weight and serum albumin every 3 months 1
• Recommended dietary energy intake: 30-35 kcal/kg/day (30-35 kcal/kg/day if ≥60 years old) 1
• Recommended protein intake: 0.6-0.75 g/kg/day with at least 50% being high biological value protein 1, 2
• If unintentional weight loss >5% or serum albumin decrease >0.3 g/dL or <4.0 g/dL, evaluate for causes and provide dietary counseling 1

Lipid Management

• Monitor for dyslipidemias (triglycerides, LDL, HDL, total cholesterol) 1
• Evaluate for secondary causes of dyslipidemia 1
• Target LDL <100 mg/dL, non-HDL cholesterol <130 mg/dL, and treat fasting triglycerides ≥500 mg/dL 1

Preparation for Renal Replacement Therapy (RRT)

• Discuss RRT modality options with the patient 1
• Consider transplant evaluation if the patient is willing and has no contraindications 1, 2
• If hemodialysis is planned, preserve veins suitable for vascular access placement 1, 2
• Refer for surgery to attempt construction of primary AV fistula 1

Important Caveats and Pitfalls

1. Medication dosing: Adjust medication doses based on current kidney function to avoid toxicity 2, 3

2. Volume status: Monitor closely for dehydration, especially when using diuretics or during illness with vomiting/diarrhea 2

3. Hyperkalemia risk: Use caution with medications that can increase potassium levels (ACE inhibitors, ARBs, spironolactone) 3, 4

   • Monitor potassium within 1 week of initiation or titration of these medications 4
   • Consider lower doses or alternate-day dosing of spironolactone (25mg every other day) 4

4. Timing of RRT: Do not base RRT initiation solely on GFR level 1

   • Consider initiating RRT if GFR <20 mL/min/1.73m² with evidence of malnutrition that doesn't respond to nutritional intervention 1

5. Multidisciplinary care: Patients with GFR <30 mL/min/1.73m² benefit from multidisciplinary nephrology care including dietary counseling, education about RRT options, and psychosocial support 1

By following this comprehensive management plan, you can help slow CKD progression, prevent complications, and prepare the patient for eventual renal replacement therapy if needed, thereby improving morbidity, mortality, and quality of life outcomes.