What are the recommendations for a patient with mildly impaired renal function (eGFR 76), elevated uric acid, and normal prostate-specific antigen (PSA) levels?

Management Recommendations for Mildly Impaired Renal Function with Elevated Uric Acid

This patient with Stage 3b CKD (eGFR 76) requires immediate nephrology referral, medication review with dose adjustments, and consideration of urate-lowering therapy given the association between hyperuricemia and progressive kidney function decline.

Nephrology Referral

• Refer to nephrology specialist now - while eGFR 76 doesn't meet absolute criteria (eGFR <30), the Canadian Society of Nephrology recommends specialist consultation for patients with declining renal function to determine etiology, assess progression risk, and establish a management plan 1
• Calculate annual eGFR decline from serial measurements to assess progression risk and consider using the Kidney Failure Risk Equation (KFRE) to predict risk of progression to kidney failure 1

Medication Safety Review - Critical Priority

Review ALL current medications immediately and adjust doses based on eGFR 76 mL/min/1.73 m² - drug accumulation from reduced renal excretion is a significant cause of adverse drug reactions, and many renally-cleared drugs require dose reduction at this level of kidney function 1

• Avoid NSAIDs entirely as they can precipitate acute kidney injury by affecting renal hemodynamics 1
• If on 5-ASA therapy for any reason, monitor renal function every 3 months (rather than annually) given existing impairment, as tubulointerstitial nephritis can occur unpredictably 2
• Verify dosing of all renally-cleared medications - anticancer drugs, antibiotics, and cardiovascular medications commonly require adjustment when eGFR falls below 60-80 mL/min 3, 4, 5

Blood Pressure and Cardiovascular Risk Management

• Target blood pressure <140/90 mmHg to reduce CKD progression 1
• If albuminuria is present (ACR ≥30 mg/g), initiate ACE inhibitor or ARB therapy 1
• Initiate statin therapy for cardiovascular risk reduction - cardiovascular disease is the leading cause of morbidity and mortality in CKD, and this patient's cholesterol of 5.3 mmol/L warrants treatment 1
• Accept up to 30% increase in serum creatinine after starting ACE inhibitor/ARB without discontinuing the medication, as this does not represent true acute kidney injury and is associated with long-term kidney protection 2

Uric Acid Management

Consider urate-lowering therapy (ULT) given the association between hyperuricemia and progressive GFR decline in CKD patients 6, 7

• While uric acid at 286 umol/L (4.8 mg/dL) is technically within reference range, high-normal uric acid levels correlate with GFR decline in CKD subjects 7
• The EULAR guidelines recommend discussing ULT with patients who have comorbidities including renal impairment, even without gout symptoms 2
• If initiating allopurinol: start at 100 mg/day and adjust maximum dosage to creatinine clearance - at eGFR 76, dose adjustment is not yet mandatory but monitor closely 2
• Target serum uric acid <360 μmol/L (6 mg/dL) if ULT is initiated 2

Monitoring Schedule

Monitor every 3 months for patients with eGFR in the 60-89 range (Stage G2-G3a), checking 1:

• Serum creatinine and eGFR
• Urinary albumin-to-creatinine ratio (if not already done)
• Serum electrolytes (sodium, potassium, bicarbonate)
• Hemoglobin
• Calcium, phosphate, and PTH (as CKD complications become prevalent below eGFR 60)

Additional Considerations

• The PSA of 0.83 ug/L with free:total ratio of 0.35 is reassuring and requires only routine age-appropriate surveillance [@evidence provided@]
• Thyroid function is normal and requires no intervention
• Important caveat: In patients with reduced muscle mass (common in elderly), "normal" creatinine levels may mask significant renal impairment - the CKD-EPI equation used here accounts for this, but serial monitoring remains essential 1
• Ensure adequate hydration status and rule out urinary obstruction as reversible causes of kidney dysfunction 1