What are the management strategies for a patient with a Glomerular Filtration Rate (GFR) below 15?

Management of GFR Below 15 mL/min/1.73 m²

A patient with GFR below 15 mL/min/1.73 m² requires immediate nephrology referral if not already established, intensive preparation for renal replacement therapy (RRT), and careful monitoring for clinical indications to initiate dialysis—but dialysis should NOT be started based on GFR alone. 1, 2

Immediate Actions

Confirm True Renal Function

• Obtain measured GFR using 24-hour urine collection for creatinine and urea clearance rather than relying solely on estimated GFR, as eGFR equations are imprecise at this level of kidney function 3, 4, 5
• This is particularly critical in patients with sarcopenia, advanced cirrhosis, or unusual creatinine generation 4

Nephrology Referral

• Ensure immediate nephrology consultation if not already established, as this stage represents imminent kidney failure requiring specialized management 6
• At GFR <15, the patient is in Stage 5 CKD and preparation for RRT becomes urgent 6

Monitoring Frequency

• Check creatinine, eGFR, and potassium at least monthly, increasing to weekly or more frequently if rapid progression or clinical instability occurs 1, 6
• Monitor hemoglobin weekly until stable, then at least monthly 7
• Check blood pressure at every clinic visit (minimum every 3 months) 1
• Monitor nutritional status (body weight and serum albumin) every 3 months 1

Clinical Indications for Dialysis Initiation

Dialysis should be initiated based on clinical symptoms, NOT GFR alone. 1, 3, 2 The following are absolute indications regardless of GFR:

Uremic Symptoms

• Pericarditis, encephalopathy, intractable nausea/vomiting, bleeding diathesis 3, 2, 6

Volume Management Issues

• Volume overload refractory to diuretic therapy 3, 2
• Uncontrolled hypertension despite maximal medical management 3, 2

Metabolic Derangements

• Hyperkalemia unresponsive to medical therapy 3, 2
• Severe metabolic acidosis 3, 2

Nutritional Deterioration

• Protein-energy malnutrition that develops or persists despite vigorous nutritional intervention, with no other apparent cause 1, 3, 2
• Declining edema-free body weight, falling serum albumin, or lean body mass <63% 2

Critical caveat: If GFR <20 mL/min/1.73 m² with refractory malnutrition despite nutritional intervention, initiate RRT 1

Conservative Management Until Dialysis Indicated

Blood Pressure Management

• Target systolic BP <130 mmHg and diastolic BP <80 mmHg 1, 6
• Use ACE inhibitor or ARB as first-line agent 1, 6
• Monitor GFR and potassium within 1 week of starting or dose escalation 1
• Do not routinely discontinue ACE-I/ARB at GFR <30 as they remain nephroprotective 1

Lipid Management

• Monitor triglycerides, LDL, HDL, and total cholesterol 1
• Target LDL <100 mg/dL, non-HDL cholesterol <130 mg/dL, and treat fasting triglycerides ≥500 mg/dL 1
• Evaluate for secondary causes of dyslipidemia including comorbid conditions and medications 1

Anemia Management

• Initiate erythropoietin when hemoglobin <10 g/dL after appropriate evaluation and iron therapy 1
• Target hemoglobin sufficient to reduce need for RBC transfusions, but do not target >11 g/dL due to increased cardiovascular risks 7
• Ensure iron supplementation when ferritin <100 mcg/L or transferrin saturation <20% 7

Medication Adjustments

Critical dose reductions required:

• Opioids: Reduce dose; use with extreme caution at GFR <15 1
• Beta-blockers: Reduce dose by 50% 1
• Metformin: CONTRAINDICATED—discontinue immediately 1, 6
• Insulin: Reduce total daily dose by 35-50% due to decreased renal clearance 6
• Canagliflozin: Maximum 100 mg daily; may continue until dialysis for cardiovascular benefit 6
• Low-molecular-weight heparins: Halve the dose or switch to conventional heparin 1
• Warfarin: Use lower doses and monitor closely due to increased bleeding risk 1
• NSAIDs: AVOID completely 1

Fluid Management

• Consult nephrology before administering IV fluids as patients are at significantly increased risk of fluid overload 6
• Monitor daily for signs of volume overload when IV fluids are necessary 6

Preparation for Renal Replacement Therapy

Patient Education and Counseling

• Provide structured education regarding preparation for RRT 1
• Discuss modality options: hemodialysis, peritoneal dialysis, and kidney transplantation 1, 6
• Encourage maintenance of employment and refer to vocational counseling per patient preference 1

Vascular Access Planning

• Preserve veins suitable for vascular access—avoid venipuncture, IV catheters, and PICC lines in non-dominant arm 1
• Refer for surgery to attempt construction of primary AV fistula if hemodialysis is planned 1

Transplant Evaluation

• Refer for transplant evaluation if patient is willing and meets UNOS criteria, unless unacceptable surgical risk exists 1
• Consider preemptive transplantation or home dialysis initiation before reaching Stage 5 CKD 6

Physical Activity

• Counsel and encourage increased physical activity 1
• Refer to physical therapy or cardiac rehabilitation if unable to walk or increase fully mobile physical activity 1

When Dialysis Is Initiated: Critical First Session Protocol

Use a "low and slow" approach to minimize dialysis disequilibrium syndrome and hemodynamic instability: 3, 2

• Initial session duration: 2-2.5 hours (not full 4 hours) 3, 2
• Reduced blood flow rates: 200-250 mL/min 3, 2
• Minimal ultrafiltration during first session—focus on clearance rather than fluid removal 3, 2
• Monitor vital signs every 15-30 minutes with close observation for neurological symptoms 3
• Gradually escalate dose over subsequent sessions as tolerated 3, 2

Critical Pitfalls to Avoid

• Never initiate dialysis based on GFR alone—early dialysis in asymptomatic patients provides no survival benefit and may cause harm 1, 3, 2
• Do not use aggressive first dialysis sessions—rapid removal of uremic toxins can cause cerebral edema, seizures, and cardiovascular instability 3
• Avoid hemodialysis-related hypotension—this may accelerate loss of residual kidney function 3, 2
• Do not routinely discontinue ACE-I/ARB at this GFR level as they remain nephroprotective 1
• Remember dialysis does not replace all kidney functions and imposes significant burden on patients 3, 2