What are the treatment options for a patient with impaired renal function, indicated by a creatinine level of 1.81 and an estimated Glomerular Filtration Rate (eGFR) of 28, consistent with stage 4 Chronic Kidney Disease (CKD)?

Management of Stage 4 Chronic Kidney Disease (Creatinine 1.81, eGFR 28)

This patient requires urgent nephrology referral and immediate preparation for renal replacement therapy, as they are approaching Stage 5 kidney failure. 1

Immediate Nephrology Referral

• Urgent nephrology consultation is mandatory for any patient with eGFR <30 mL/min/1.73m², as this represents Stage 4 CKD approaching kidney failure. 2, 1
• Referral should occur immediately when eGFR falls below 30 mL/min/1.73m² to allow adequate time for dialysis access planning and transplant evaluation. 2, 1

Assessment for Urgent Dialysis Indications

Before planning elective renal replacement therapy, evaluate for life-threatening complications requiring emergency dialysis 1:

• Severe hyperkalemia (potassium >6.5 mEq/L or ECG changes showing peaked T-waves, widened QRS)
• Pulmonary edema unresponsive to diuretics
• Severe metabolic acidosis (pH <7.2)
• Uremic symptoms: pericarditis, encephalopathy, bleeding diathesis, intractable nausea/vomiting
• Volume overload refractory to medical management

Preparation for Renal Replacement Therapy

Dialysis Access Planning

• Arteriovenous fistula creation should be arranged now at eGFR 28 mL/min/1.73m², as fistulas require 3-6 months to mature before use and are ideally created when GFR is 15-20 mL/min/1.73m². 1
• Dialysis initiation typically occurs at GFR <10 mL/min/1.73m² in the absence of urgent indications, giving this patient several months to prepare. 1

Transplant Evaluation

• Kidney transplantation evaluation should begin immediately, as preemptive transplantation (before dialysis) offers the best outcomes. 1
• Transplantation is the optimal treatment for Stage 4-5 CKD and may be performed before dialysis initiation. 1

Medical Management

Medication Adjustments

• All renally cleared medications must be dose-adjusted for eGFR 28 mL/min/1.73m². 1
• Strictly avoid nephrotoxic agents: NSAIDs, aminoglycosides, and iodinated contrast (or use only with extreme caution and adequate hydration). 1
• ACE inhibitors or ARBs should be continued if already prescribed for proteinuria or hypertension, with careful monitoring of creatinine and potassium. 2
• Monitor serum creatinine and potassium levels regularly when using ACE inhibitors, ARBs, or diuretics. 2

Metabolic Complications Management

Anemia 1:

• Check hemoglobin, ferritin, transferrin saturation, vitamin B12, and folate
• Initiate erythropoiesis-stimulating agents and iron supplementation as indicated

Mineral Bone Disease 1:

• Monitor calcium, phosphorus, parathyroid hormone, and vitamin D levels
• Initiate phosphate binders and active vitamin D analogs as needed

Metabolic Acidosis 1:

• Check serum bicarbonate
• Consider sodium bicarbonate supplementation if bicarbonate <22 mEq/L

Hyperkalemia 1:

• Implement dietary potassium restriction (<2-3 grams daily)
• Discontinue potassium-sparing medications (spironolactone, amiloride, triamterene)
• Avoid potassium-containing salt substitutes

Volume Management 1:

• Careful sodium restriction (2 grams daily)
• Fluid management to avoid both overload and depletion
• Diuretic adjustment as needed

Dietary Modifications

• Protein intake should be approximately 0.8 g/kg body weight per day for non-dialysis CKD patients to slow progression. 2
• Once dialysis begins, higher protein intake will be required. 2

Monitoring Complications

Cardiovascular Risk

• CKD Stage 4 markedly increases cardiovascular risk, requiring aggressive management of hypertension, diabetes, and dyslipidemia. 2
• Blood pressure control is critical, with ACE inhibitors or ARBs as first-line agents for those with proteinuria. 2

Chronic Kidney Disease Complications

• Evaluate and manage all CKD complications when eGFR <60 mL/min/1.73m², including anemia, bone disease, acidosis, and electrolyte abnormalities. 2

Critical Pitfalls to Avoid

• Do not rely on serum creatinine alone to assess kidney function in acute changes, as creatinine assumes steady-state conditions. 2
• Do not use eGFR equations (MDRD, CKD-EPI) to assess day-to-day changes during acute illness, as they are designed for chronic stable kidney disease. 2
• Do not delay nephrology referral hoping for spontaneous improvement at this level of kidney function—permanent damage is likely present. 2
• Do not wait until symptoms develop to plan dialysis access, as urgent catheter placement carries higher infection and complication risks. 1