What is the best course of action for a patient with stable impaired renal function and an eGFR of 60?

Management of Stable Stage 3a Chronic Kidney Disease

For a patient with stable creatinine (1.19 mg/dL) and eGFR of 60 mL/min/1.73 m² for 8 months, continue monitoring renal function every 3-12 months while optimizing blood pressure control and screening for albuminuria to guide further management. 1

Initial Assessment and Classification

Your patient has Stage 3a CKD (eGFR 45-59 mL/min/1.73 m²), which represents mildly to moderately decreased kidney function. 1 The stability over 8 months is reassuring, as the trend in renal function is often more clinically significant than absolute values. 1

Critical Next Steps

Measure urinary albumin-to-creatinine ratio (UACR) immediately if not already done. 1 This is essential because:

• UACR determines CKD staging completeness and guides treatment intensity 1
• Albuminuria ≥30 mg/g indicates higher cardiovascular and CKD progression risk 1
• Two of three specimens collected within 3-6 months should be abnormal before confirming persistent albuminuria 1

Monitoring Strategy

Renal Function Monitoring Frequency

Monitor eGFR and creatinine every 3-12 months for stable Stage 3a CKD. 1 More frequent monitoring (every 3 months) is warranted if: 1

• Initiating or titrating medications affecting renal function (ACE inhibitors, ARBs, diuretics, SGLT2 inhibitors)
• Blood pressure is uncontrolled
• New albuminuria develops
• Any acute illness or dehydration occurs

Important caveat: eGFR formulas (MDRD, CKD-EPI) are validated for stable or slowly declining renal function over months to years, not acute changes. 1 For acute deterioration, use absolute serum creatinine values instead. 1

Blood Pressure Management

Target blood pressure <140/90 mmHg as a minimum; consider <130/80 mmHg if albuminuria is present. 1 Hypertension is a major driver of CKD progression, and antihypertensive therapy reduces both albuminuria and cardiovascular events. 1

• If UACR is 30-299 mg/g: Use ACE inhibitor or ARB (not both) 1
• If UACR is ≥300 mg/g: ACE inhibitor or ARB is strongly recommended 1
• If UACR is <30 mg/g with normal blood pressure: ACE inhibitor/ARB not indicated for renal protection alone 1

Monitor serum creatinine and potassium within 1-2 weeks after starting or adjusting ACE inhibitor/ARB doses. 1 Accept up to 30% increase in creatinine if it stabilizes, as this represents hemodynamic changes rather than kidney damage. 1

Risk Factor Assessment and Modification

Annual Screening Requirements

Assess these factors at least annually: 1

• Diabetes status: If diabetic, ensure HbA1c optimization and consider SGLT2 inhibitor therapy, which reduces CKD progression even at eGFR 30-60 mL/min/1.73 m² 1
• Cardiovascular disease: Screen for dyslipidemia, smoking, family history of premature coronary disease 1
• Medication review: Avoid NSAIDs and other nephrotoxins; adjust drug dosing based on eGFR 1
• Dietary supplements: Specifically ask about creatine supplements, which can falsely elevate serum creatinine 2

Complications Monitoring at eGFR <60 mL/min/1.73 m²

Evaluate and manage potential CKD complications: 1

• Anemia (check hemoglobin)
• Secondary hyperparathyroidism (check calcium, phosphate, PTH, vitamin D)
• Metabolic acidosis (check serum bicarbonate)
• Electrolyte disturbances (potassium, sodium)

When to Refer to Nephrology

Consider nephrology referral if: 1

• eGFR declines to <30 mL/min/1.73 m² (Stage 4 CKD) 1
• Rapid eGFR decline (>5 mL/min/year or >10 mL/min over 5 years)
• Development of nephrotic-range proteinuria (UACR >2,200 mg/g or >300 mg/24h) 1
• Active urinary sediment (RBCs, WBCs, cellular casts) suggesting glomerulonephritis 1
• Resistant hypertension despite multiple agents 1
• Unexplained eGFR decline without obvious cause 1
• Uncertainty about CKD etiology 1

Common Pitfalls to Avoid

Do not rely solely on serum creatinine to assess renal function, as it can remain normal until GFR falls significantly below 60 mL/min/1.73 m². 1 This is especially true in patients with low muscle mass, older adults, or those with severe neurological conditions. 1

Do not combine ACE inhibitors and ARBs together, as this increases adverse events (hyperkalemia, AKI) without additional benefit. 1

Do not assume stability means no intervention is needed. Even with stable eGFR, uncontrolled blood pressure or undetected albuminuria can drive silent progression. 1

Monitor loop diuretics and spironolactone carefully if used, as these can adversely affect renal function, particularly in heart failure patients. 3