What is the management of moderate renal disease with an estimated Glomerular Filtration Rate (eGFR) of 35?

Management of Moderate Renal Disease (eGFR 35)

For a patient with eGFR 35 mL/min/1.73 m² (CKD Stage 3b), management should focus on slowing progression through blood pressure control with RAS blockade, addressing proteinuria, managing complications, and preparing for potential renal replacement therapy.

Blood Pressure and Proteinuria Management

• Target blood pressure <140/90 mmHg, with consideration of <130 mmHg if tolerated 1
• Initiate or maximize ACE inhibitor or ARB therapy as first-line agents for blood pressure control and proteinuria reduction, even at this level of kidney function 1, 2
• Accept up to 30% increase in serum creatinine after starting RAS blockade without discontinuing therapy, as this represents hemodynamic changes rather than kidney injury 1
• Dietary sodium restriction to <2.0 g/day (<90 mmol/day) to enhance blood pressure control and reduce proteinuria 1
• Consider adding mineralocorticoid receptor antagonists for refractory proteinuria, with careful potassium monitoring 1

Proteinuria Assessment and Monitoring

• Measure urinary albumin-to-creatinine ratio (UACR) at baseline and monitor every 3-12 months to assess disease progression and treatment response 1
• A sustained reduction of >30% in proteinuria over 2 years is associated with improved renal and cardiovascular outcomes 1
• More frequent monitoring (twice yearly) is recommended at this eGFR level, particularly when on RAS blockade 1

Cardiovascular Risk Reduction

• Initiate statin therapy for cardiovascular risk reduction, as reduced eGFR <60 mL/min/1.73 m² is independently associated with elevated atherosclerotic cardiovascular disease risk 1
• Assess ASCVD risk based on LDL-C, apolipoprotein B, triglycerides, and lipoprotein(a) levels 1
• Align statin dosage intensity to ASCVD risk 1

Diabetes Management (if applicable)

• Target HbA1c <7.0% for most patients, with individualization based on hypoglycemia risk and comorbidities 1
• Consider SGLT2 inhibitors to reduce CKD progression and cardiovascular events in patients with diabetes and CKD 3
• Metformin can be continued at eGFR 35 mL/min/1.73 m² with appropriate dose adjustment 4
• Accept transient eGFR reduction of up to 25% after initiating SGLT2 inhibitors, attributed to hemodynamic changes 1

Dietary Modifications

• Protein restriction to 0.8 g/kg/day for patients with eGFR <60 mL/min/1.73 m² 1
• Avoid protein intake <0.6 g/kg/day due to malnutrition risk 1
• Emphasize plant-based protein sources 1
• Caloric intake target of 30-35 kcal/kg/day at this eGFR level 1
• Maintain normal body mass index to limit CKD progression 1

Complication Management

• Screen for and manage anemia with hemoglobin monitoring and consideration of iron supplementation or erythropoiesis-stimulating agents 1
• Evaluate and treat mineral bone disease with monitoring of calcium, phosphorus, parathyroid hormone, and vitamin D levels 1
• Assess for metabolic acidosis and consider bicarbonate supplementation if serum bicarbonate <22 mEq/L 1
• Monitor potassium levels regularly, especially when on RAS blockade or mineralocorticoid receptor antagonists 1

Medication Management

• Review all medications for appropriate dosing at eGFR 35 mL/min/1.73 m² 1
• Avoid nephrotoxic agents, particularly NSAIDs and aminoglycosides 1, 4
• Exercise caution with iodinated contrast media; consider alternative imaging or prophylactic measures 4
• Ensure vaccinations are current: pneumococcal, influenza, herpes zoster (Shingrix), and hepatitis B 1

Infection Prophylaxis and Screening

• Screen for tuberculosis, hepatitis B, hepatitis C, HIV, and syphilis in clinically appropriate patients before considering any immunosuppression 1
• Consider prophylactic trimethoprim-sulfamethoxazole if high-dose immunosuppression is required 1

Nephrology Referral and Preparation

• Immediate nephrology referral is strongly recommended at eGFR <45 mL/min/1.73 m² for coordinated care 1, 4
• Begin education about renal replacement therapy options (hemodialysis, peritoneal dialysis, transplantation) 1
• Discuss vascular access planning for potential future dialysis, as access creation should occur when eGFR approaches 20-25 mL/min/1.73 m² 1
• Consider transplant evaluation if appropriate, as preemptive transplantation offers superior outcomes 1

Monitoring Schedule

• eGFR and UACR every 3-6 months at this stage 1
• Serum potassium monitoring with each eGFR check, especially on RAS blockade 1
• Lipid panel every 3-12 months after statin initiation 1
• Hemoglobin, calcium, phosphorus, and PTH monitoring every 6-12 months 1

Critical Pitfalls to Avoid

• Do not discontinue ACE inhibitors or ARBs for creatinine increases <30% from baseline in the absence of volume depletion or hyperkalemia 1
• Do not use maximally tolerated doses of RAS blockade rather than subtherapeutic doses, as clinical trials demonstrating efficacy used maximal dosing 1
• Do not delay nephrology referral, as earlier involvement improves outcomes and preparation for renal replacement therapy 1, 4
• Do not assume eGFR alone captures all kidney function; always assess proteinuria and clinical context 5, 6

Prognosis Assessment

• A decline in eGFR of ≥30% over 2 years is strongly associated with progression to ESRD and should prompt treatment intensification 7
• At baseline eGFR of 35 mL/min/1.73 m², the 10-year risk of ESRD with a 30% decline is approximately 64% versus 18% with stable eGFR 7
• Proteinuria reduction is a validated surrogate endpoint for slowing CKD progression 1