What are the management steps for a patient with a Glomerular Filtration Rate (GFR) of 25, indicating severe Chronic Kidney Disease (CKD)?

Management of Severe CKD (GFR 25 mL/min/1.73 m²)

You need to refer this patient to nephrology immediately for co-management and begin preparation for kidney replacement therapy, as a GFR of 25 mL/min/1.73 m² represents Stage 4 CKD requiring specialist involvement. 1

Immediate Nephrology Referral

• Refer to nephrology now - patients with eGFR <30 mL/min/1.73 m² require nephrologist participation in care according to National Kidney Foundation guidelines 1
• This referral threshold is consistently recommended across multiple guidelines to prevent late referral, which is associated with increased mortality after dialysis initiation 1, 2
• The patient is approaching Stage 5 CKD (eGFR <15 mL/min/1.73 m²), when preparation for kidney replacement therapy should begin 1

Cardiovascular and Kidney Protection Medications

SGLT2 Inhibitors

• Start an SGLT2 inhibitor immediately if eGFR ≥20 mL/min/1.73 m² and the patient has albuminuria ≥200 mg/g or heart failure 1
• SGLT2 inhibitors reduce CKD progression and cardiovascular events in patients with eGFR as low as 20 mL/min/1.73 m² 1
• Do not discontinue for the expected initial reversible eGFR decline 1

ACE Inhibitors or ARBs

• Continue or initiate ACE inhibitor or ARB if the patient has albuminuria and hypertension 1, 3
• Target blood pressure <140/90 mm Hg (some guidelines suggest <130/80 mm Hg for higher-risk patients) 1, 3
• Do not discontinue for creatinine increases <30% in the absence of volume depletion 2

Nonsteroidal Mineralocorticoid Receptor Antagonists

• Consider adding finerenone if the patient has type 2 diabetes, albuminuria >30 mg/g despite maximum tolerated RAS inhibitor, and normal serum potassium 1
• Start with 10 mg daily given eGFR 25 mL/min/1.73 m² 1
• Monitor potassium at 1 month, then every 4 months; hold if K+ >5.5 mmol/L 1

Statins

• Prescribe a statin for cardiovascular risk reduction regardless of baseline cholesterol 4, 3

Assess and Manage CKD Complications

At GFR 25 mL/min/1.73 m², you must evaluate and treat complications that become prevalent when GFR falls below 30 mL/min/1.73 m² 1:

Anemia

• Check complete blood count 1
• Evaluate iron stores, vitamin B12, and folate 1
• Consider erythropoiesis-stimulating agents if hemoglobin is low and iron-replete 1

Mineral and Bone Disorder

• Measure serum calcium, phosphorus, and PTH every 3-6 months 1
• Measure alkaline phosphatase annually 1
• Check 25-hydroxyvitamin D levels and correct deficiency (target >30 ng/mL) 1
• Restrict dietary phosphorus if hyperphosphatemia develops 1

Metabolic Acidosis

• Check serum bicarbonate 1
• Treat if bicarbonate <18 mmol/L to prevent bone disease and muscle wasting 1
• Monitor to avoid bicarbonate exceeding normal range 1

Hyperkalemia

• Monitor potassium regularly, especially if on RAS inhibitors or MRA 1
• Adjust diet and medications if K+ >5.0 mmol/L 1

Dietary Management

• Restrict dietary protein to 0.6-0.75 g/kg/day with at least 50% from high biological value sources 1
• This reduces uremic symptoms and may slow CKD progression 1
• Ensure adequate caloric intake to prevent malnutrition 1
• Restrict sodium intake to help control blood pressure 3

Medication Safety

• Review all medications and adjust doses based on eGFR 25 mL/min/1.73 m² 4, 3
• Avoid nephrotoxins, particularly NSAIDs 4, 3
• Avoid metformin if eGFR <30 mL/min/1.73 m² due to lactic acidosis risk 3
• Adjust antibiotic dosing for renal function 4

Preparation for Kidney Replacement Therapy

• Begin education about dialysis and transplant options now, as preparation should start when GFR <30 mL/min/1.73 m² 1
• Discuss hemodialysis, peritoneal dialysis, and kidney transplantation options 1
• Consider vascular access planning (arteriovenous fistula creation) if hemodialysis is anticipated, as fistulas require months to mature 1
• Evaluate for transplant candidacy and consider living donor evaluation 1

Monitoring Frequency

• Assess eGFR and albuminuria every 3-6 months at this stage 1
• Monitor more frequently if rapid progression (decline >5 mL/min/1.73 m²/year) 1, 2
• Check electrolytes, calcium, phosphorus, and PTH every 3-6 months 1

Additional Diabetes Management (if applicable)

• Target HbA1c ≤7% to slow progression 3
• Add GLP-1 receptor agonist if not at glycemic target despite metformin and SGLT2 inhibitor, prioritizing agents with cardiovascular benefits 1

Common Pitfalls to Avoid

• Do not delay nephrology referral - late referral (<1 year before dialysis) worsens outcomes 1, 2
• Do not stop ACE inhibitors/ARBs for minor creatinine increases (<30%) without excluding volume depletion 2
• Do not use NSAIDs - they accelerate kidney function decline 4, 3
• Do not ignore albuminuria - it requires treatment even if blood pressure is controlled 3
• Do not wait until GFR <15 to discuss dialysis - preparation must begin now 1