Management of Mildly Impaired Kidney Function (eGFR 60 mL/min/1.73m²)
This patient with eGFR 60 mL/min/1.73m² (CKD Stage G3a) and normal electrolytes requires annual monitoring of kidney function and electrolytes, medication dose verification, minimization of nephrotoxin exposure, and evaluation for CKD complications, but does not require immediate intervention given the stable, normal electrolyte values. 1
Current Clinical Status
The laboratory values show:
- eGFR 60 mL/min/1.73m²: Defines CKD Stage G3a (mild-to-moderate decrease in kidney function) 1
- All electrolytes within normal range: Na 140-141 mmol/L (normal 135-145), K 4.4 mmol/L (normal 3.5-5.2), Cl 101-104 mmol/L (normal 95-110), HCO3 25-27 mmol/L (normal 22-32) 1
- Stable creatinine: 94-95 μmol/L with consistent eGFR readings 1
Surveillance and Monitoring Requirements
Annual monitoring is mandatory for patients with eGFR <60 mL/min/1.73m²: 1
- Measure eGFR and albuminuria (UACR) at least annually 1
- Monitor serum potassium periodically, especially if on ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists 1
- Screen for CKD complications every 6-12 months for Stage G3 CKD: electrolytes, blood pressure, volume status, hemoglobin, calcium, phosphate, PTH, and vitamin D 1
Medication Management
Verify appropriate dosing for all medications based on eGFR 60 mL/min/1.73m²: 1
Specific Drug Considerations:
Metformin: Continue without dose adjustment at eGFR 60 mL/min/1.73m² 1
DPP-4 Inhibitors (if diabetic): 1
- Sitagliptin: 100 mg daily (no adjustment needed at eGFR >50 mL/min/1.73m²)
- Linagliptin: No dose adjustment required
- Alogliptin: 25 mg daily (no adjustment at eGFR >60 mL/min/1.73m²)
ACE Inhibitors/ARBs: No dose adjustment needed, but monitor potassium and creatinine within 2 weeks of initiation 1, 2
NSAIDs: Minimize exposure due to nephrotoxicity risk 1
Nephrotoxin Avoidance
Implement "sick-day rules" - temporarily discontinue the following during acute illness that increases AKI risk: 1
- ACE inhibitors/ARBs
- Diuretics
- NSAIDs
- Metformin
- Lithium
- Digoxin
Iodinated contrast: Use lowest possible dose, ensure adequate hydration with saline before/during/after procedure, and measure eGFR 48-96 hours post-procedure 1
Blood Pressure and Cardiovascular Management
Target blood pressure <130/80 mmHg for CKD patients 1
- ACE inhibitors or ARBs are preferred if hypertension and albuminuria are present 1
- Monitor for up to 30% increase in serum creatinine after initiating ACE inhibitors/ARBs (this is expected and not true AKI) 1
Dietary Recommendations
Protein intake: Approximately 0.8 g/kg/day 1
Fluid intake: 1.5-2 liters daily unless edematous 2
Potassium restriction: Not required at eGFR 60 mL/min/1.73m² with normal potassium levels; consider restriction only if eGFR <20 mL/min/1.73m² or <50 mL/min/1.73m² with medications that raise potassium 2
When to Refer to Nephrology
Consider nephrology referral if: 1
- Progressive decline in eGFR
- Development of albuminuria
- Difficulty managing complications
- eGFR approaches <30 mL/min/1.73m² (approaching need for renal replacement therapy) 1
Critical Pitfalls to Avoid
Do not assume stable kidney function: Even with normal electrolytes, annual monitoring is essential as CKD can progress silently 1
Do not use herbal remedies: These are contraindicated in CKD due to unpredictable nephrotoxicity 1
Do not overlook medication reconciliation: Many drugs require dose adjustment even at eGFR 60 mL/min/1.73m² 1
Do not ignore volume status: Weight and volume should be monitored regularly, as sodium retention can occur with eGFR <60 mL/min/1.73m² 2