What is the management plan for a patient with severe kidney impairment, indicated by an estimated Glomerular Filtration Rate (eGFR) of 24?

Management of Severe Kidney Impairment (eGFR 24 mL/min/1.73 m²)

A patient with eGFR 24 mL/min/1.73 m² requires immediate nephrology referral, comprehensive evaluation for CKD complications, preparation for kidney replacement therapy, and strict medication management including avoidance of nephrotoxic agents. 1

Immediate Nephrology Referral

Urgent referral to nephrology is mandatory at this level of kidney function. 1, 2

• eGFR <30 mL/min/1.73 m² is an absolute indication for specialist kidney care services 1
• This represents Stage 4 CKD (severely reduced kidney function), placing the patient at high risk for progression to kidney replacement therapy 1
• The 5-year risk of requiring kidney replacement therapy exceeds 3-5% at this eGFR level, warranting planning and preparation 1

Monitoring Frequency and Laboratory Surveillance

Laboratory evaluations should occur every 1-3 months at this stage of CKD. 1

• Monitor eGFR, electrolytes, and albuminuria every 1-3 months for Stage 4 CKD 1
• Assess hemoglobin and iron studies every 3-5 months 1
• Check serum calcium, phosphate, PTH, and vitamin D every 3-5 months for metabolic bone disease screening 1
• Evaluate for volume overload, blood pressure control, and weight at every clinical contact 1

CKD Complication Management

Cardiovascular Risk Reduction

Continue RAAS inhibition (ACE inhibitors or ARBs) if tolerated, as cardiovascular disease is the leading cause of mortality in advanced CKD. 1, 2

• Patients with eGFR 24 are at markedly increased cardiovascular risk, with nearly 3-fold higher incidence of heart failure compared to normal kidney function 3
• Blood pressure target should be <140/90 mmHg, with more intensive control if significant albuminuria is present 1
• Statin therapy is indicated for cardiovascular risk reduction 2

SGLT2 Inhibitors and Novel Therapies

SGLT2 inhibitors are recommended if eGFR ≥20 mL/min/1.73 m² and should be continued at this level. 1

• For type 2 diabetes with CKD, SGLT2 inhibitors reduce CKD progression and cardiovascular events when eGFR ≥20 mL/min/1.73 m² 1
• Nonsteroidal mineralocorticoid receptor antagonists can be considered if eGFR ≥25 mL/min/1.73 m² for cardiovascular risk reduction and slowing CKD progression 1

Anemia Management

Initiate erythropoiesis-stimulating agents (ESAs) only when hemoglobin falls below 10 g/dL, targeting the lowest dose to avoid transfusions without exceeding 11 g/dL. 4

• Evaluate iron status before initiating ESA therapy; administer supplemental iron when ferritin <100 mcg/L or transferrin saturation <20% 4
• Starting dose for epoetin alfa is 50-100 Units/kg three times weekly (intravenous or subcutaneous) 4
• Monitor hemoglobin weekly until stable, then monthly 4
• Critical warning: Targeting hemoglobin >11 g/dL increases mortality, cardiovascular events, and stroke risk 4

Metabolic Complications

Screen for and treat hyperkalemia, metabolic acidosis, hyperphosphatemia, and secondary hyperparathyroidism. 1, 2

• Electrolyte abnormalities become prevalent when eGFR falls below 60 mL/min/1.73 m² and worsen progressively 1
• Avoid NSAIDs entirely, as they increase hyperkalemia risk and can precipitate acute kidney injury, especially with concurrent RAAS inhibitors 5, 2
• Use acetaminophen as first-line for pain management 5

Dietary Protein Restriction

Restrict dietary protein intake to 0.8 g/kg body weight per day for non-dialysis Stage 4 CKD. 1

• This target applies specifically to patients with eGFR <30 mL/min/1.73 m² who are not on kidney replacement therapy 1
• Protein restriction slows CKD progression but requires monitoring for malnutrition 1
• Screen for malnutrition twice annually using validated assessment tools 1

Medication Management and Nephrotoxin Avoidance

Adjust all medication dosing based on eGFR and avoid nephrotoxic agents. 2

• Many antibiotics and oral hypoglycemic agents require dose adjustment at eGFR 24 2
• Absolute contraindications: NSAIDs (including meloxicam) should be avoided entirely 5
• Exercise caution with radiocontrast media; assess AKI risk using validated tools before cardiac procedures 1
• Calcineurin inhibitors (if used for conditions like lupus nephritis) should be used cautiously when eGFR <45 mL/min/1.73 m² due to increased nephrotoxicity risk 1

Preparation for Kidney Replacement Therapy

Begin education and planning for kidney replacement therapy modalities at this stage. 1

• Provide access to multidisciplinary care team including dietary counseling, medication management, and education about dialysis modalities and transplant options 1
• Consider vascular access planning (arteriovenous fistula creation) if progression to dialysis is anticipated, as fistulas require 3-6 months to mature 1
• Discuss home dialysis options (peritoneal dialysis or home hemodialysis) and kidney transplantation, including preemptive transplant evaluation 1

Specific Considerations for Underlying Etiology

Identify and address the underlying cause of CKD if not already established. 1, 2

• If cause is uncertain, hereditary kidney disease, or recurrent nephrolithiasis, specialist evaluation is required 1
• For diabetic kidney disease: ensure optimal glycemic control, though avoid hypoglycemia risk with adjusted medication dosing 1
• For glomerulonephritis with eGFR 24: immunosuppression decisions require careful risk-benefit assessment, as severe kidney impairment may limit treatment options 1

Common Pitfalls to Avoid

• Do not target hemoglobin >11 g/dL with ESA therapy - this increases mortality and cardiovascular events 4
• Do not prescribe NSAIDs - even short courses can precipitate acute-on-chronic kidney injury 5, 2
• Do not delay nephrology referral - eGFR <30 requires specialist management 1, 2
• Do not use standard drug dosing - most medications require adjustment at this eGFR level 2
• Do not overlook cardiovascular risk - this is the leading cause of death in advanced CKD, not progression to dialysis 3