What is the best course of treatment for a patient with severe chronic kidney disease (CKD) and impaired renal function?

Management of Stage 4 CKD with Metabolic Acidosis

This patient with creatinine 2.76, eGFR 25 mL/min/1.73 m², and CO₂ 33 requires immediate nephrology referral, initiation of kidney-preserving therapies including RAAS inhibitors (if not contraindicated), SGLT2 inhibitors, dietary modifications, and preparation for kidney replacement therapy, as they have reached the critical threshold where structured predialysis education and multidisciplinary care significantly reduce mortality. 1

Immediate Actions and Nephrology Referral

• Urgent nephrology referral is mandatory because patients with eGFR <30 mL/min/1.73 m² are at high risk of CKD progression and require specialized management to prevent complications and prepare for potential kidney replacement therapy 2
• Patients referred to nephrology within 90 days of dialysis initiation have a 40-60% increased risk of death during their first year of renal replacement therapy compared to those with earlier referral 3
• Early nephrology involvement enables predialysis education, implementation of preventive measures, and structured interdisciplinary care that improves outcomes 4

Disease-Modifying Pharmacotherapy

RAAS Inhibition

• Initiate or optimize ACE inhibitors or ARBs to reduce intraglomerular pressure and slow progression, as these have the greatest weight of evidence for slowing CKD progression 5, 6
• Only 25-40% of eligible CKD patients in the US receive these medications despite their proven benefit 1
• Monitor potassium and creatinine closely; accept up to 30% increase in creatinine if stable thereafter 2

SGLT2 Inhibitors

• Add SGLT2 inhibitor therapy as these agents preserve kidney function by reducing intraglomerular pressure independently of blood pressure and glucose control 6
• These represent disease-modifying treatment that positively affects kidney disease trajectory 1

Management of Metabolic Acidosis

• The CO₂ of 33 mEq/L suggests mild metabolic acidosis (normal range typically 23-29 mEq/L), which is a common complication requiring treatment 2
• Acidosis correction is a potentially useful therapeutic target that may slow CKD progression, though evidence is still being developed 5
• Consider sodium bicarbonate supplementation to maintain serum bicarbonate >22 mEq/L, while monitoring for sodium overload and hypertension 2

Monitoring for CKD Complications

Essential Laboratory Monitoring

• Check serum calcium, phosphate, PTH, and 25-hydroxyvitamin D levels to assess for CKD-mineral bone disorder 7, 8
• Monitor for hyperkalemia, anemia (hemoglobin/hematocrit), and secondary hyperparathyroidism 2
• Frequency: calcium and phosphate every 3 months; PTH every 3-6 months at this stage 7

Specific Interventions Based on Findings

• If 25(OH)D <30 ng/mL: supplement with ergocalciferol according to deficiency severity 7
• Maintain total elemental calcium intake at 800-1,000 mg/day (including dietary sources and supplements) 7
• If hyperphosphatemia develops: initiate dietary phosphate restriction and consider non-calcium-based phosphate binders like sevelamer or lanthanum 8, 9, 10
• If anemia present: evaluate and treat according to guidelines; severe anemia was found in preponderance of incident ESRD patients with mean hematocrit 27.7% 3

Blood Pressure Management

• Target BP <140/90 mmHg at minimum; only 27% of CKD patients in NHANES III achieved this target 3
• Consider more stringent target of <130/80 mmHg if tolerated, particularly with albuminuria 2
• Inadequate prescription of antihypertensive drugs and poor diagnostic recognition of CKD are major barriers 3

Dietary Modifications

• Implement plant-dominant, low-protein, low-salt diet to mitigate glomerular hyperfiltration and preserve renal function 6
• Dietary adjustments can lead to favorable alterations in acid-base homeostasis and gut microbiome 6
• Protein restriction should be carefully balanced to avoid malnutrition 2

Medication Review and Dose Adjustments

• Comprehensive medication review is essential as many drugs require dose adjustment based on kidney function 1
• Avoid nephrotoxins, particularly NSAIDs, which should be discontinued 2
• Adjust dosing for antibiotics, oral hypoglycemic agents, and other renally cleared medications 2
• Review and deprescribe unnecessary medications to reduce polypharmacy burden 1

Preparation for Kidney Replacement Therapy

Patient Education

• Provide timely education about kidney failure treatment options including kidney transplantation, peritoneal dialysis, hemodialysis (home or in-center), and conservative treatment 1
• Include family members and caregivers in education sessions 1
• Education should begin now at Stage 4 CKD because disease progression is unpredictable and patients vary in their ability to assimilate information 1

Vascular Access Planning

• Begin planning for vascular access if hemodialysis is anticipated, as early access creation improves outcomes 3
• Autologous fistula is preferred over prosthetic graft or catheter; only 29% of incident US hemodialysis patients had fistulas versus 30% with catheters 3
• Tunneled catheters are associated with 39% annual increased risk of death 3

Transplant Evaluation

• Consider early transplant evaluation and living donor assessment, as transplantation offers survival and quality-of-life benefits 1
• Most eligible recipients have not been placed on transplant waiting lists 6 months after beginning dialysis 3

Cardiovascular Risk Reduction

• Initiate statin therapy for cardiovascular risk reduction, as cardiovascular disease is a major cause of morbidity and mortality in CKD 2
• Managing CKD-associated cardiovascular risk is crucial given the high burden of complications 6
• Monitor and treat other cardiovascular risk factors aggressively 2

Common Pitfalls to Avoid

• Do not delay nephrology referral: 35% of CKD patients are seen within 90 days of requiring RRT, contributing to poor outcomes 3
• Do not underdose or withhold RAAS inhibitors due to fear of hyperkalemia or creatinine elevation without attempting careful titration 1
• Avoid calcium-based phosphate binders if hypercalcemia present or if calcium-phosphorus product >55 to prevent extraskeletal calcification 7
• Do not overlook preventive care: <40% of incident ESRD patients receive recommended cancer screening (mammography, PAP, PSA) or HbA1c monitoring 3
• Avoid routine use of calcitriol or active vitamin D analogs at this stage; reserve for severe progressive hyperparathyroidism 7

Interdisciplinary Care Model

• Transition to team-based care involving nephrologist, dietitian, pharmacist, and nurse educator 1
• Multidisciplinary care shows greater benefits for patients with advanced CKD than primary care alone 1
• Communication within and between disciplines becomes increasingly important as complexity increases 1