What is the management plan for an elderly female with impaired renal function (eGFR 28) and elevated creatinine (1.81)?

Management of Stage 4 CKD (eGFR 28) in an Elderly Female

This patient requires nephrology referral and comprehensive management focused on slowing progression, managing complications, and optimizing medication safety.

Immediate Actions

Nephrology Referral

• Refer to nephrology specialist services immediately as this patient has an eGFR <30 mL/min/1.73 m² (Stage 4 CKD, G4), which meets absolute criteria for specialist consultation 1
• The Canadian Society of Nephrology guidelines specifically recommend referral for GFR <30 mL/min/1.73 m² 1
• While some stable, isolated cases may only require advice rather than formal ongoing care, initial consultation is essential to determine etiology, assess progression risk, and establish management plan 1

Diagnostic Workup

• Measure urine albumin-to-creatinine ratio (ACR) or protein-to-creatinine ratio (PCR) to assess proteinuria and stratify risk 2, 3
• Repeat creatinine and eGFR in 3 months to confirm chronicity and assess rate of progression 2
• Evaluate for reversible causes: review medications (especially NSAIDs, nephrotoxins), assess hydration status, check for urinary obstruction 1, 2
• Important caveat: In elderly females with reduced muscle mass, serum creatinine may underestimate the severity of renal dysfunction 1

Risk Factor Management

Blood Pressure Control

• Target blood pressure <140/90 mm Hg to reduce CKD progression 2
• Use ACE inhibitors or ARBs if albuminuria is present (ACR ≥300 mg/g or ≥30 mg/mmol) 1, 2
• Monitor potassium and creatinine closely after initiating RAAS inhibitors at this level of kidney function 1

Cardiovascular Disease Prevention

• Initiate statin therapy for cardiovascular risk reduction, as cardiovascular disease is the leading cause of morbidity and mortality in CKD 1, 3
• Consider SGLT2 inhibitor if diabetic, as these reduce both cardiovascular and kidney disease progression risk 3
• Manage associated comorbidities aggressively, particularly cardiovascular disease 1

Glycemic Control (if diabetic)

• Target HbA1c ≤7% to slow CKD progression 2
• Consider GLP-1 receptor agonists for additional cardiorenal protection in diabetic patients 3

Medication Safety

Dose Adjustments

• Review ALL medications and adjust doses based on eGFR 28 mL/min/1.73 m² 1, 2
• Drug accumulation from reduced renal excretion is the most important cause of adverse drug reactions in elderly patients with CKD 1
• Many renally-cleared drugs require significant dose reduction at this level of kidney function 1

Avoid Nephrotoxins

• Discontinue NSAIDs completely - these are contraindicated and can precipitate acute kidney injury 2
• Avoid other nephrotoxic agents including aminoglycosides, contrast agents (use with caution and adequate hydration only when essential) 2
• Be cautious with medications that affect renal hemodynamics 1

Special Considerations in Elderly

• Elderly patients have reduced muscle mass, so "normal" creatinine levels may mask significant renal impairment 1
• Pharmacokinetics are altered: reduced hepatic metabolism (CYP450), decreased renal clearance, and altered volume of distribution 1
• Use CKD-EPI equation for most accurate eGFR estimation in elderly patients 1

Monitor for CKD Complications

Assess and Treat

• Anemia: Check hemoglobin; consider erythropoiesis-stimulating agents if indicated 2
• Metabolic acidosis: Check serum bicarbonate; correct if present to slow progression 2
• Mineral and bone disorder: Monitor calcium, phosphate, PTH, and vitamin D levels 2
• Hyperkalemia: Monitor potassium regularly, especially if on RAAS inhibitors 1

Monitoring Schedule

Frequency of Follow-up

• At eGFR 28 (Stage G4), monitoring should be every 3 months for eGFR and albuminuria 1
• More frequent monitoring if evidence of rapid progression (decline >5 mL/min/1.73 m²/year or >25% decline) 1
• The interdisciplinary approach is most beneficial for patients with eGFR <30 mL/min/1.73 m² 1

Assess Progression Risk

Define Rate of Decline

• Calculate annual eGFR decline from serial measurements 1
• Rapid progression is defined as decline ≥5 mL/min/1.73 m²/year 1
• Consider using Kidney Failure Risk Equation (KFRE) to predict risk of progression to kidney failure and guide intensity of management 3, 4

Common Pitfalls to Avoid

• Do not rely on serum creatinine alone - it commonly underestimates renal insufficiency in elderly patients, particularly women with low muscle mass 1
• Do not delay nephrology referral - at eGFR 28, specialist input is essential regardless of stability 1
• Do not continue nephrotoxic medications - even "stable" Stage 4 CKD is vulnerable to acute deterioration 2
• Do not assume age alone determines prognosis - physiological age differs from chronological age; assess function individually 1