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)

You need immediate nephrology referral and must begin preparing for renal replacement therapy now, as your kidney function has reached Stage 4 CKD and is approaching kidney failure. 1

Immediate Nephrology Referral

• Urgent nephrology consultation is required for any patient with eGFR <30 mL/min/1.73m², as recommended by the American Diabetes Association. 1
• Referral should occur immediately to allow adequate time for dialysis access planning and transplant evaluation. 1
• Do not delay nephrology referral hoping for spontaneous improvement—permanent kidney damage is likely present at this level of function. 1

Assessment for Emergency Dialysis Indications

Evaluate immediately for life-threatening complications that may require urgent dialysis: 1

• Severe hyperkalemia (potassium >6.5 mEq/L or ECG changes) 2
• Pulmonary edema unresponsive to diuretics 1, 2
• Severe metabolic acidosis (pH <7.2) 1, 2
• Uremic symptoms: pericarditis, encephalopathy, bleeding, intractable nausea/vomiting 1, 2
• Volume overload refractory to medical management 1, 2

Preparation for Renal Replacement Therapy

Dialysis Access Planning

• Arteriovenous fistula creation should be arranged now at eGFR 28 mL/min/1.73m². 1
• Fistulas require 3-6 months to mature before use and are ideally created when GFR is 15-20 mL/min/1.73m². 1, 2
• This timing is critical—you are at the optimal window for access creation before dialysis becomes necessary. 1

Transplant Evaluation

• Kidney transplantation evaluation should begin immediately, as preemptive transplantation offers the best outcomes. 1
• Transplantation is the optimal treatment and may be performed preemptively (before dialysis) or after dialysis initiation. 2

Medical Management

Medication Adjustments

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

Blood Pressure Management

• Target systolic blood pressure <120 mm Hg based on the SPRINT trial data showing mortality benefit in non-diabetic CKD patients with eGFR 20-60 (death HR: 0.72,95% CI 0.53-0.99). 3
• If diabetic, target blood pressure <130/80 mm Hg per ACCORD trial findings. 3

Management of Metabolic Complications

Anemia Management

• Check hemoglobin, ferritin, transferrin saturation, vitamin B12, and folate. 1, 2
• Evaluate and treat anemia as it commonly develops when eGFR <60 mL/min/1.73m². 1

Mineral Bone Disease

• Monitor calcium, phosphorus, parathyroid hormone, and vitamin D levels. 1, 2
• CKD-mineral bone disorder requires active management at this stage. 1

Metabolic Acidosis

• Check serum bicarbonate and consider supplementation if <22 mEq/L. 2

Hyperkalemia Management

• Implement dietary potassium restriction. 1, 2
• Discontinue potassium-sparing medications. 1, 2

Volume Status

• Careful fluid and sodium management to avoid both overload and depletion. 2

Dietary Modifications

• Protein intake should be approximately 0.8 g/kg body weight per day for non-dialysis CKD patients to slow progression. 1
• Implement sodium restriction to help control blood pressure and volume status. 1

Cardiovascular Risk Management

• CKD Stage 4 markedly increases cardiovascular risk, requiring aggressive management of hypertension, diabetes, and dyslipidemia. 1
• The cardiovascular pathways in CKD may differ from the general population, with medial arterial calcification playing a larger role than traditional plaque atherosclerosis. 3
• Despite these differences, traditional cardiovascular risk factor management remains important and should be intensified. 3

Critical Monitoring

• Do not rely on serum creatinine alone to assess kidney function in acute changes, as creatinine assumes steady-state conditions. 1
• Regular monitoring of electrolytes, acid-base status, and volume status is essential at this stage. 1
• Evaluate and manage all CKD complications when eGFR <60 mL/min/1.73m², including anemia, bone disease, acidosis, and electrolyte abnormalities. 1

Timeline for Dialysis Initiation

• The recommended threshold for initiating kidney replacement therapy is GFR <10 mL/min/1.73m² in the absence of urgent indications. 2
• Individual factors influencing timing include dialysis access availability, transplantation candidacy, peritoneal dialysis eligibility, age, declining nutritional status, fluid balance, and medication compliance. 2
• At your current eGFR of 28, you have time to prepare properly, but action must begin now. 1