What is the management plan for a patient with an estimated Glomerular Filtration Rate (eGFR) of 44, indicating Impaired renal function?

Management of Patient with eGFR 44 mL/min/1.73 m²

This patient has CKD Stage 3b (moderate to severe GFR decrease), which requires comprehensive management focused on slowing progression, managing complications, and preparing for potential renal replacement therapy. 1

Classification and Risk Stratification

• eGFR of 44 mL/min/1.73 m² places this patient in CKD Stage 3b (30-44 mL/min/1.73 m²), indicating moderate to severe kidney function decline 1
• Stage 3b CKD carries significantly increased cardiovascular risk and mortality, with hazard ratios exceeding 1.4 for cardiovascular disease and over 3-fold increased risk of death compared to earlier stages 2, 3
• Immediate assessment of albuminuria (UACR) is essential to complete risk stratification, as the combination of eGFR and albuminuria determines overall prognosis and treatment intensity 1

Essential Diagnostic Workup

Obtain the following immediately:

• Urinary albumin-to-creatinine ratio (UACR) to assess proteinuria and guide treatment decisions 1
• Complete metabolic panel including serum electrolytes, calcium, phosphate, and bicarbonate to screen for CKD complications 1
• Complete blood count to evaluate for anemia 1
• Parathyroid hormone (PTH) and vitamin D levels to assess for metabolic bone disease 1
• Lipid panel for cardiovascular risk assessment 1
• Hemoglobin A1c if diabetes is present or suspected 1

Blood Pressure Management

Target blood pressure: <140/90 mmHg 1

• If UACR >300 mg/g OR if patient has diabetes with hypertension, initiate ACE inhibitor or ARB as first-line therapy 1
• If UACR 30-300 mg/g with diabetes and hypertension, ACE inhibitors or ARBs are also preferred 1
• Monitor serum potassium and creatinine 1-2 weeks after initiating or adjusting RAAS blockade 1
• Do NOT combine ACE inhibitors with ARBs - this combination increases adverse events without additional benefit 1

Glycemic Control (if diabetic)

For patients with diabetes:

• First-line: Metformin is recommended at eGFR 44 mL/min/1.73 m² 1

  • Use standard dosing but monitor eGFR every 3-6 months 1
  • Consider dose reduction to half the usual dose given proximity to eGFR 30-44 range 1
  • Discontinue if eGFR falls below 30 mL/min/1.73 m² 1

• Second-line: Add SGLT2 inhibitor for renal and cardiovascular protection 1

  • SGLT2 inhibitors slow GFR loss, reduce albuminuria, and provide cardiovascular benefits independent of glycemic effects 1

• Third-line: Consider long-acting GLP-1 receptor agonist if glycemic targets not met with metformin and SGLT2i 1

  • Prioritize agents with documented cardiovascular benefits (dulaglutide, liraglutide, semaglutide) 1

Dietary Modifications

• Protein intake: approximately 0.8 g/kg/day - neither higher nor lower 1

  • Higher protein intake (>1.3 g/kg/day) accelerates kidney function loss and increases cardiovascular mortality 1
  • Lower intake provides no additional benefit 1

• Sodium restriction: reduce intake if currently >3.3 g/day, but routine restriction to <2 g/day is not recommended 1

  • Individualize based on blood pressure control and volume status 1

• Potassium restriction may be necessary depending on serum potassium levels, particularly with RAAS blockade 1

Monitoring Schedule

At eGFR 44 mL/min/1.73 m², monitor every 6 months (twice yearly): 1

• eGFR and serum creatinine 1
• UACR 1
• Electrolytes, calcium, phosphate 1
• Complete blood count 1
• PTH if abnormal initially 1

Increase monitoring frequency to 3-4 times yearly if: 1

• Albuminuria is in higher categories (UACR >300 mg/g)
• eGFR continues to decline
• Complications develop

Nephrology Referral

Refer to nephrology now - eGFR <45 mL/min/1.73 m² warrants specialist involvement 1

Additional referral indications include:

• UACR >60 mg/mmol or protein excretion >1 g/day 1
• Rapid decline in eGFR (>5 mL/min/1.73 m² per year) 1
• Difficulty managing complications (anemia, bone disease, electrolyte abnormalities) 1

Medication Dosing Adjustments

Review ALL medications and adjust doses based on eGFR of 44 mL/min/1.73 m²: 1

• Calculate absolute clearance (mL/min) by multiplying eGFR by patient's actual body surface area divided by 1.73 1
• Many medications require dose reduction at this level of kidney function 1
• Avoid nephrotoxic agents (NSAIDs, aminoglycosides, contrast agents when possible) 1

Preparation for Progression

While not imminent, begin education about: 1

• Renal replacement therapy options (hemodialysis, peritoneal dialysis, transplantation) should be discussed when eGFR approaches 30 mL/min/1.73 m² 1
• Vascular access planning typically begins when eGFR <20 mL/min/1.73 m² 1
• The average decline in elderly patients is approximately 16.6 mL/min/1.73 m² per decade, though this accelerates with age 3

Critical Pitfalls to Avoid

• Do not ignore this eGFR as "normal for age" - Stage 3b CKD carries substantial morbidity and mortality risk regardless of age 2, 4, 3
• Do not delay nephrology referral - 48.7% of Stage 3 CKD cases are missed by routine screening, and Stage 3b patients have the highest risk (20%) of progressing to renal failure 4
• Do not combine ACE inhibitors with ARBs - this increases harm without benefit 1
• Do not restrict protein below 0.8 g/kg/day - this provides no benefit and may cause malnutrition 1