What are the treatment options for a patient with a Glomerular Filtration Rate (GFR) of 14, indicating severe kidney dysfunction?

Management of GFR 14 mL/min/1.73 m²

A patient with GFR 14 mL/min/1.73 m² has Stage 4 chronic kidney disease (severe renal insufficiency) and requires immediate nephrology referral for preparation for renal replacement therapy, comprehensive monitoring every 3 months, and careful medication management to prevent further deterioration and complications. 1, 2

Disease Classification and Urgency

• This GFR falls within Stage 4 CKD (GFR 15-29 mL/min/1.73 m²), classified as severe renal insufficiency, one stage before kidney failure requiring dialysis. 1
• Immediate nephrology referral is mandatory at GFR <30 mL/min/1.73 m², as patients require evaluation for renal replacement therapy. 2, 3
• Renal function is a powerful independent predictor of prognosis, and most patients at this level will progress to requiring dialysis or transplantation. 1

Reversible Causes Assessment

Before proceeding with chronic management, evaluate and correct reversible factors:

• Discontinue all nephrotoxic medications immediately, particularly NSAIDs and certain antibiotics. 1, 2
• Assess for volume depletion, hypotension, or conversely volume overload and right heart failure causing renal venous congestion. 1
• Evaluate for urinary obstruction (including prostatic obstruction in men). 1
• Review recent contrast exposure and consider renal artery stenosis if there was an immediate and large fall in GFR after starting ACE inhibitors or ARBs. 1

Medication Management

ACE Inhibitors/ARBs

• Continue ACE inhibitors or ARBs unless contraindicated, as small reductions in GFR should not lead to treatment discontinuation unless marked. 1
• The disposition of enalapril and enalaprilat in patients with renal insufficiency is similar to normal function until GFR is ≤30 mL/min, at which point the effective half-life is prolonged and dosing adjustments are required. 4
• Lisinopril elimination becomes clinically important when GFR is below 30 mL/min, requiring dose reduction. 5
• Monitor serum potassium and creatinine within 1-2 weeks after any dose adjustment. 2

Diuretics

• Thiazide diuretics are less effective at very low eGFR; switch to loop diuretics for volume management. 1

Renally-Cleared Drugs

• Adjust dosages of all renally-excreted drugs, as they may accumulate at this level of renal impairment. 1, 2

Comprehensive Laboratory Monitoring (Every 3 Months)

Anemia Workup

• Check hemoglobin; if <12 g/dL in women or <13 g/dL in men, perform complete anemia workup including iron studies, as erythropoietin deficiency becomes prevalent at this GFR. 2, 3

Mineral-Bone Disorder Assessment

• Measure serum calcium, phosphorus, and intact parathyroid hormone (iPTH) at baseline and every 3 months. 2, 3
• If iPTH >100 pg/mL (or >1.5 times upper limit of normal), check 25(OH) vitamin D levels. 3

Cardiovascular Risk Evaluation

• Obtain complete lipid panel including triglycerides, LDL, HDL, and total cholesterol. 2, 3
• Consider statin therapy regardless of baseline lipid levels, targeting LDL <100 mg/dL. 2

Nutritional Status

• Monitor body weight and serum albumin every 3 months to detect protein-energy malnutrition. 2

Electrolytes

• Monitor serum potassium and creatinine regularly, especially when using ACE inhibitors, ARBs, or diuretics. 2

Blood Pressure Management

• Check blood pressure at every clinic visit, minimum every 3 months. 2, 3
• Target blood pressure <130/80 mmHg. 2, 3
• Use ACE inhibitors or ARBs as first-line agents for hypertension. 2
• If hypertension persists despite ACE inhibitor/ARB, beta-blocker, and MRA, add amlodipine or felodipine. 1
• Do NOT use moxonidine (increased mortality) or alpha-adrenoceptor antagonists (neurohumoral activation, fluid retention, worsening heart failure). 1

Dietary Management

• Limit dietary protein intake to approximately 0.8 g/kg body weight per day. 2
• Restrict sodium and manage fluid balance based on volume status. 1

Renal Replacement Therapy Planning

• Begin discussions immediately about renal replacement therapy modalities: hemodialysis, peritoneal dialysis, and kidney transplantation. 2, 3
• Theoretical considerations support initiation of dialysis at GFR approximately 10 mL/min/1.73 m², though timing should be individualized based on symptoms and complications. 1
• If protein-energy malnutrition develops or persists despite vigorous attempts to optimize intake, and there is no apparent cause other than low nutrient intake, recommend initiation of kidney replacement therapy. 1
• Consider vascular access planning (arteriovenous fistula creation) well before anticipated need for hemodialysis. 1

Common Pitfalls to Avoid

• Do not rely solely on serum creatinine levels, as they grossly overestimate kidney function at this stage. 1
• Clinical symptoms and signs are poorly predictive of reduced renal function until GFR <15 mL/min/1.73 m². 6
• Do not abruptly discontinue ACE inhibitors/ARBs for small GFR reductions; only discontinue if there is a marked and immediate fall suggesting renal artery stenosis. 1
• Avoid contrast-enhanced CT imaging (CTA) as it is generally contraindicated at GFR <30 mL/min/1.73 m² due to significantly increased risk of acute kidney injury; use duplex Doppler ultrasound or non-contrast MRA instead. 7
• Do not delay nephrology referral, as preparation for renal replacement therapy takes time and improves outcomes. 2, 3