What is the management approach for a patient with a Glomerular Filtration Rate (GFR) of 16, indicating severe Impaired Renal Function?

Management of GFR 16 mL/min/1.73 m²

A patient with GFR 16 mL/min/1.73 m² has Stage 4 severe chronic kidney disease and requires immediate nephrology referral, preparation for renal replacement therapy (RRT), and comprehensive management to prevent progression to kidney failure. 1

Immediate Actions

Nephrology Referral

• Refer immediately to nephrology for formal consultation and ongoing care management given GFR <30 mL/min/1.73 m² 1
• This GFR level represents severe renal insufficiency (GFR 15-29 mL/min/1.73 m²) and is approaching kidney failure threshold 1
• Patients at this level face high risk for kidney failure requiring dialysis, cardiovascular events, and death 2

Renal Replacement Therapy Planning

• Begin structured education regarding RRT modalities (hemodialysis, peritoneal dialysis, transplantation) immediately 1
• Discuss RRT options with the patient now, as this is critical at GFR <30 mL/min/1.73 m² 1
• If hemodialysis is chosen, refer for arteriovenous fistula creation now to allow maturation before dialysis need 1
• Preserve veins suitable for vascular access—avoid venipuncture and IV lines in non-dominant forearm 1

Transplant Evaluation

• Refer for transplant evaluation if patient is willing and meets candidacy criteria, as this should occur at GFR <30 mL/min/1.73 m² 1
• Exclude patients with unacceptable surgical risk or those not meeting UNOS Ethics Committee criteria 1

Monitoring and Assessment

Fluid and Electrolyte Management

• Monitor for fluid overload signs daily: edema, pulmonary crackles, increased respiratory rate 3, 4
• Check electrolytes (particularly potassium and sodium) regularly, ideally daily if receiving IV fluids 3, 4
• Monitor renal function (serum creatinine, BUN) frequently—at minimum weekly, daily if acutely ill 4
• Exercise extreme caution with IV fluid administration: patients with eGFR <30 mL/min/1.73 m² are at significantly increased risk of fluid overload and further kidney damage 3
• Consider nephrology consultation before administering IV fluids for volume expansion 3

Nutritional Management

• Restrict dietary protein to 0.8 g/kg/day (using ideal body weight) to slow CKD progression 1, 4
• Avoid protein intake <0.6 g/kg/day due to malnutrition risk 1
• Emphasize plant-based protein sources 1
• Restrict dietary sodium to <2.0 g/day (<90 mmol/day) to control blood pressure, edema, and proteinuria 1
• Target caloric intake of 30-35 kcal/kg/day for patients with eGFR <60 mL/min/1.73 m² 1
• Provide diet assessment and counseling by qualified personnel 1
• If malnutrition develops that does not respond to nutritional intervention, initiate RRT 1

Cardiovascular Risk Management

• Monitor for dyslipidemias: measure triglycerides, LDL, HDL, and total cholesterol 1
• Target LDL <100 mg/dL and non-HDL cholesterol <130 mg/dL 1
• Treat fasting triglycerides ≥500 mg/dL 1
• Evaluate for secondary causes of dyslipidemia including comorbid conditions and medications 1
• Implement heart-healthy diet with fat <30% of total calories 1

Medication Management

Critical Contraindications

• Metformin is absolutely contraindicated at GFR 16 mL/min/1.73 m²—discontinue immediately if patient is taking it 5
• Metformin is contraindicated in patients with eGFR below 30 mL/min/1.73 m² due to risk of lactic acidosis 5

Medication Adjustments

• Review all medications for renal dosing adjustments 4
• For immunosuppressive therapy (if treating glomerulonephritis), adjust dosing based on GFR level and monitor therapeutic drug levels 1
• Consider nephrology consultation before initiating any new medications, particularly those with renal excretion 4

Lifestyle and Supportive Care

Physical Activity

• Counsel and encourage increased physical activity if patient is sedentary 1
• Refer to physical therapy or cardiac rehabilitation if unable to walk or increase fully mobile physical activity 1

Psychosocial Support

• Encourage maintaining employment and offer vocational counseling per patient preference 1
• Screen for and treat depression, as this is common in advanced CKD 1

Immunizations

• Update vaccination status, particularly influenza and pneumococcal vaccines 1
• Screen for latent infections before any immunosuppression if treating underlying glomerular disease 1

Common Pitfalls to Avoid

• Do not rely on GFR alone to initiate RRT—timing should be based on clinical symptoms (uremia, fluid overload, refractory hyperkalemia, metabolic acidosis) rather than a specific GFR threshold 1
• Do not use standard eGFR equations (MDRD, CKD-EPI) for acute changes—these require steady-state creatinine and are unreliable in unstable kidney function 1
• Do not overlook the need for more frequent monitoring—failure to recognize early signs of worsening renal function or fluid overload can result in severe complications 4
• Do not delay vascular access creation—AV fistulas require months to mature, and late referral often necessitates temporary catheter use with higher infection risk 1
• Do not administer nephrotoxic agents (NSAIDs, aminoglycosides, contrast media) without careful risk-benefit assessment and nephrology input 3

Prognosis and Patient Counseling

• At GFR 16 mL/min/1.73 m², patients face substantial risk of progression to kidney failure, cardiovascular events, and death within 2-4 years 2
• Clinical symptoms and signs are poorly predictive of reduced renal function until GFR falls below 15 mL/min/1.73 m² 6
• Provide realistic expectations about disease trajectory and importance of preparation for RRT 1, 2