Management of eGFR 25 (Stage 4 CKD)
Refer this patient to nephrology immediately, as consultation when stage 4 CKD develops (eGFR <30 mL/min/1.73 m²) reduces costs, improves quality of care, and delays dialysis. 1
Immediate Nephrology Referral
- All patients with eGFR <30 mL/min/1.73 m² require nephrology referral to prepare for potential renal replacement therapy and manage complex complications. 1, 2
- Begin structured education about dialysis and transplantation options now, as preparation takes months and progression rates are unpredictable. 2
- Evaluate for preemptive kidney transplantation, including living donor assessment. 2
Blood Pressure Management
Target and First-Line Therapy
- Target systolic blood pressure <120 mmHg when tolerated using standardized office measurement. 2, 3
- Start an ACE inhibitor or ARB as first-line therapy for blood pressure control and proteinuria reduction, titrated to maximum tolerated dose. 1, 2, 3
- Monitor serum creatinine and potassium within 2-4 weeks of starting or increasing ACE inhibitor/ARB dose. 2, 3
- Continue ACE inhibitor/ARB unless creatinine rises >30% within 4 weeks of initiation. 2, 3
- Never combine ACE inhibitor with ARB due to increased risk of hyperkalemia and acute kidney injury. 3
Volume Control
- Use loop diuretics (not thiazides) for volume overload, as thiazides are ineffective at this eGFR level. 2, 3
- Restrict dietary sodium to <2g per day to enhance blood pressure control. 2, 3
Diabetes Management (If Applicable)
SGLT2 Inhibitors
- Start an SGLT2 inhibitor with proven kidney or cardiovascular benefit if the patient has type 2 diabetes, as eGFR 25 is above the initiation threshold of ≥20 mL/min/1.73 m². 1, 2, 4
- Continue SGLT2 inhibitor even if eGFR falls below 20 mL/min/1.73 m² unless dialysis is initiated. 1, 4
Other Glucose-Lowering Agents
- Reduce metformin dose to 1000 mg daily or discontinue, as eGFR 25 is below the safe threshold of 30 mL/min/1.73 m². 1
- Consider glipizide as the preferred sulfonylurea due to lack of active metabolites. 4
- DPP-4 inhibitors (sitagliptin, saxagliptin, linagliptin) require dose adjustments at this eGFR level. 4
- Insulin requires careful dose reduction due to decreased renal clearance. 4
Additional Diabetes Therapy
- Consider a nonsteroidal mineralocorticoid receptor antagonist (finerenone) if the patient has type 2 diabetes, normal potassium, and albuminuria (ACR ≥30 mg/g), as it reduces cardiovascular and kidney outcomes. 1
- Add a GLP-1 receptor agonist with proven cardiovascular benefit if glycemic targets are not met with metformin and/or SGLT2 inhibitor. 1
Cardiovascular Risk Reduction
- Start a moderate-intensity statin for primary prevention or high-intensity statin if the patient has known atherosclerotic cardiovascular disease. 1
- CKD patients have markedly elevated cardiovascular mortality requiring aggressive risk factor management. 2
Monitoring for Complications
Mineral and Bone Disorder
- Check serum calcium and phosphorus every 3-6 months. 2
- Check PTH every 6-12 months. 2
- Measure alkaline phosphatase annually or more frequently if PTH is elevated. 2
- Measure 25(OH)D levels and correct deficiency using general population treatment strategies. 2
Anemia
- Perform complete blood count at least monthly after initial stabilization. 2
- Assess and treat underlying causes of anemia using standard CKD measures. 2
Electrolyte and Metabolic Monitoring
- Monitor for hyperkalemia regularly, which can be managed with dietary restriction and potassium binders rather than immediately discontinuing ACE inhibitor/ARB. 2, 3
- Monitor for metabolic acidosis and treat if present, as correction slows CKD progression. 2
Preparation for Renal Replacement Therapy
Vascular Access Planning
- Create arteriovenous fistula in advance for patients likely to require hemodialysis, as maturation takes weeks to months. 2
- For patients interested in peritoneal dialysis, delay AVF creation and focus on PD catheter planning. 2
Education and Decision-Making
- Provide structured pre-dialysis education to patient and family members about all renal replacement options. 2
- Education should begin now to allow adequate time for informed decision-making. 2
Medication Safety
- Avoid nephrotoxic agents including NSAIDs, COX-2 inhibitors, and iodinated contrast media. 2, 5
- Adjust dosing for all renally cleared medications based on eGFR. 5, 6
Urgent Indications for Dialysis Initiation
- Refer urgently if the patient develops uremic symptoms, BUN >100 mg/dL, altered mental status, refractory volume overload, severe hyperkalemia, uremic pericarditis, or severe metabolic acidosis (pH <7.2). 2, 3