What is the management plan for a patient with severely impaired renal function (eGFR of 15)?

Management of eGFR 15 mL/min/1.73 m²

Immediate nephrology referral is mandatory for a patient with eGFR 15 mL/min/1.73 m², as this represents Stage 4 CKD (severely decreased kidney function) and requires specialist management to prepare for renal replacement therapy and manage complications. 1

Nephrology Referral

• Refer immediately to nephrology for any patient with eGFR <30 mL/min/1.73 m² (Stage 4 CKD), as consultation at this stage reduces costs, improves quality of care, and delays dialysis. 1
• The Canadian Society of Nephrology specifically recommends formal referral for GFR <30 mL/min/1.73 m² unless the finding is stable and isolated with clear diagnosis in elderly patients with limited life expectancy. 1
• At eGFR 15, the patient is approaching Stage 5 CKD (kidney failure, defined as eGFR <15 or dialysis requirement), making preparation for renal replacement therapy urgent. 1

Monitoring Frequency

• Monitor creatinine, eGFR, urinary albumin excretion, and potassium twice yearly for patients with Stage 4 CKD (eGFR 15-29 mL/min/1.73 m²). 1
• Increase monitoring frequency to quarterly or more often if there is rapid progression, new medication initiation (SGLT2 inhibitors, ACE inhibitors, ARBs), or change in clinical status. 1
• Monitor electrolytes and renal function daily if administering IV fluids, as patients with eGFR 15 are at significantly increased risk of fluid overload and further kidney damage. 2

Screening for CKD Complications

When eGFR is <30 mL/min/1.73 m², screen for and manage the following complications: 1

Anemia Management

• Evaluate iron status before initiating erythropoietin therapy and maintain iron repletion throughout treatment. 3
• For CKD patients on dialysis, initiate erythropoietin when hemoglobin <10 g/dL at 50-100 Units/kg three times weekly IV or subcutaneously. 3
• Target hemoglobin should not exceed 11 g/dL, as higher targets increase risks of death, serious cardiovascular events, and stroke. 3

Mineral and Bone Disorder

• Monitor serum calcium twice weekly during initial treatment phase with phosphate binders. 4
• For end-stage renal disease patients, initiate calcium acetate at 2 capsules with each meal, gradually increasing to 3-4 capsules per meal to control serum phosphorus. 4
• Maintain calcium-phosphorus product below 55 mg²/dL². 4
• Avoid concurrent calcium supplements or calcium-based antacids with calcium acetate due to hypercalcemia risk. 4

Secondary Hyperparathyroidism

• Screen for and manage secondary hyperparathyroidism as part of CKD-mineral bone disease management. 1

Metabolic Acidosis

• Evaluate and correct metabolic acidosis, which commonly develops at this level of kidney function. 1

Glycemic Management (if diabetic)

• Target HbA1c <7.0% for most patients, though higher targets (7.0-8.0%) may be appropriate for those with severe comorbidities, limited life expectancy, or high hypoglycemia risk. 1
• Monitor HbA1c twice yearly, increasing to quarterly if not at target or therapy changes. 1

Medication Adjustments at eGFR 15-29 mL/min/1.73 m²:

SGLT2 Inhibitors: 1

• Canagliflozin: Maximum 100 mg daily; may continue for kidney and cardiovascular benefit until dialysis
• Dapagliflozin: Do not initiate if eGFR <25; may continue 10 mg daily if already on therapy
• Empagliflozin: Not recommended for initiation at eGFR <30

GLP-1 Receptor Agonists: 1

• Dulaglutide, liraglutide, semaglutide: No dose adjustment required
• Exenatide: Not recommended; contraindicated at eGFR <30
• Lixisenatide: Clinical experience limited; monitor closely

DPP-4 Inhibitors: 1

• Sitagliptin: 25 mg daily maximum
• Saxagliptin: 2.5 mg daily maximum
• Alogliptin: 6.25 mg daily maximum
• Linagliptin: No adjustment needed

Insulin: 1

• Reduce total daily dose by 35-50% due to decreased renal clearance and reduced gluconeogenesis
• Titrate conservatively to avoid hypoglycemia

Metformin: 1

• Contraindicated at eGFR <30 mL/min/1.73 m²; discontinue immediately

Sulfonylureas: 1

• Glyburide: Contraindicated
• Glipizide: Initiate conservatively at 2.5 mg daily
• Glimepiride: Initiate at 1 mg daily

Blood Pressure Management

• Target systolic BP <130 mmHg (but not <120 mmHg) and diastolic BP <80 mmHg (but not <70 mmHg). 1
• Use ACE inhibitors or ARBs as first-line agents for blood pressure control and kidney protection. 1
• Expect transient eGFR reduction of up to 25% after initiating ACE inhibitors or ARBs due to hemodynamic changes; this does not indicate intrinsic kidney damage. 1
• Monitor for hyperkalemia with ACE inhibitor/ARB use, particularly at this level of kidney function. 1

Fluid Management Precautions

• Consult nephrology before administering IV fluids to patients with eGFR 15, as they are at significantly increased risk of fluid overload. 2
• Monitor daily for signs of fluid overload when IV fluids are necessary. 2
• Consider more frequent renal function monitoring during volume expansion. 2

Preparation for Renal Replacement Therapy

• Begin patient education about progressive nature of kidney disease and potential need for dialysis or transplantation. 1
• Discuss options for renal replacement therapy (hemodialysis, peritoneal dialysis, kidney transplantation). 1
• Consider vascular access planning for hemodialysis or peritoneal dialysis catheter placement. 1
• Evaluate for kidney transplant candidacy and consider preemptive transplant listing if appropriate. 1

Common Pitfalls to Avoid

• Do not delay nephrology referral thinking you can manage Stage 4 CKD in primary care; specialist involvement at this stage significantly improves outcomes. 1
• Do not continue metformin at eGFR <30; this is an absolute contraindication due to lactic acidosis risk. 1
• Do not target hemoglobin >11 g/dL with erythropoietin therapy, as this increases mortality and cardiovascular events. 3
• Do not administer IV fluids liberally without nephrology input, as fluid overload risk is substantial at this level of kidney function. 2
• Do not use glyburide for diabetes management in advanced CKD due to hypoglycemia risk. 1
• Do not ignore hypercalcemia risk when using calcium-based phosphate binders; monitor calcium twice weekly initially. 4