What is the management plan for a 74-year-old female with stage 3b chronic kidney disease?

Management of a 74-Year-Old Female with Stage 3b Chronic Kidney Disease (eGFR 44)

For a 74-year-old female with an eGFR of 44 (stage 3b CKD), management should focus on slowing disease progression, addressing cardiovascular risk, and monitoring for complications. The following comprehensive approach is recommended:

Monitoring and Evaluation

• Monitor eGFR, electrolytes, and therapeutic medication levels regularly, approximately every 3-5 months for stage G3b CKD 1
• Screen for complications including hypertension, volume overload, electrolyte abnormalities, metabolic acidosis, anemia, and metabolic bone disease 1
• Assess urinary albumin excretion to further stratify risk and guide therapy 1
• Perform thorough medication review periodically and at transitions of care to assess adherence, continued indications, and potential drug interactions 1

Blood Pressure Management

• Target blood pressure ≤140/90 mmHg for patients with urine albumin excretion <30 mg/24 hours 1
• For patients with albuminuria ≥30 mg/24 hours, aim for more intensive control with target ≤130/80 mmHg 1
• Use ACE inhibitors or ARBs as first-line therapy, especially if albuminuria is present 1
• Do not discontinue renin-angiotensin system blockade for increases in serum creatinine (≤30%) in the absence of volume depletion 1

Cardiovascular Risk Reduction

• Initiate statin therapy as this patient is over 50 years with eGFR <60 ml/min/1.73 m² (strong recommendation) 1, 2
• Consider statin/ezetimibe combination to maximize LDL cholesterol reduction 2
• Prescribe low-dose aspirin if the patient has established cardiovascular disease 1
• Consider SGLT2 inhibitors if the patient has type 2 diabetes, as they reduce CKD progression and cardiovascular events 1

Medication Management

• Review and limit use of over-the-counter medicines and dietary/herbal remedies that may be harmful 1
• Avoid nephrotoxic medications including NSAIDs 1
• Consider GFR when dosing medications cleared by the kidneys 1
• For medications with narrow therapeutic windows, consider using equations that combine both creatinine and cystatin C for more accurate dosing 1

Dietary Recommendations

• Recommend dietary protein intake of 0.8 g/kg body weight per day (the recommended daily allowance) 1
• Restrict dietary sodium to <2,300 mg/day to control blood pressure and reduce cardiovascular risk 1
• Individualize dietary potassium based on serum potassium levels 1
• Consider a plant-based "Mediterranean-style" diet to further reduce cardiovascular risk 1

Management of Complications

• Screen for and manage anemia, metabolic acidosis, and metabolic bone disease as these become more prevalent in stage G3 CKD 1
• Monitor for gout and consider low-dose colchicine or glucocorticoids rather than NSAIDs for acute gout management 1
• Do not use agents to lower serum uric acid in asymptomatic hyperuricemia to delay CKD progression 1

Referral to Specialist Care

• Consider nephrology referral for this patient with eGFR <45 ml/min/1.73 m² 1
• Immediate referral is warranted for uncertainty about etiology, difficult management issues, or rapidly progressing kidney disease 1

Patient Education

• Educate the patient regarding expected benefits and possible risks of medications 1
• Establish collaborative relationships with other healthcare providers and pharmacists to ensure drug stewardship 1
• Emphasize the importance of medication adherence and regular monitoring 1

Special Considerations

• If the patient has diabetes, maintain appropriate glycemic control with medications that have renal benefits 1
• For imaging studies requiring contrast, assess risk for AKI and follow radiology society guidelines for contrast administration 1
• If gadolinium-containing contrast media is required, use American College of Radiology group II and III gadolinium-based contrast agents 1