How to manage a patient with impaired renal function, indicated by a serum creatinine of 1.74 and estimated glomerular filtration rate (eGFR) of 32 milliliters per minute (mL/min), likely with stage 4 chronic kidney disease (CKD)?

Management of Stage 4 Chronic Kidney Disease (eGFR 32 mL/min)

This patient requires immediate nephrology referral, as eGFR of 32 mL/min represents Stage 4 CKD and mandates urgent specialist consultation to prepare for renal replacement therapy. 1

Immediate Actions Required

Urgent Nephrology Referral

• Refer to nephrology immediately when eGFR falls below 30 mL/min/1.73m², though this patient at 32 mL/min is already at the threshold requiring urgent consultation 1
• Do not delay referral hoping for spontaneous improvement—permanent kidney damage is present at this level of function 1
• The referral allows adequate time for dialysis access planning and transplant evaluation before progression to Stage 5 1

Assess for Emergency Dialysis Indications

Evaluate immediately for life-threatening complications requiring urgent dialysis: 1, 2

• Severe hyperkalemia (potassium >6.5 mEq/L or ECG changes) 2
• Pulmonary edema unresponsive to diuretics 1, 2
• Severe metabolic acidosis (pH <7.2) 2
• Uremic symptoms: pericarditis, encephalopathy, bleeding, intractable nausea/vomiting 2
• Volume overload refractory to medical management 1, 2

Preparation for Renal Replacement Therapy

Dialysis Access Planning

• Arrange arteriovenous fistula creation now, as fistulas require 3-6 months to mature and are ideally created when GFR is 15-20 mL/min/1.73m² 1, 2
• At eGFR 32 mL/min, this patient is approaching the optimal window for access creation 1

Transplant Evaluation

• Begin kidney transplantation evaluation immediately, as preemptive transplantation (before dialysis initiation) offers the best outcomes 1, 2

Medical Management

Medication Review and Adjustment

• Dose-adjust all renally cleared medications for eGFR 32 mL/min/1.73m² 1, 2
• Avoid nephrotoxic agents: NSAIDs, aminoglycosides, and use contrast dye only with extreme caution and adequate hydration 2
• Continue ACE inhibitors or ARBs if already prescribed for proteinuria or hypertension, with careful monitoring of creatinine and potassium 1
• For patients on lisinopril with creatinine clearance ≥30 mL/min, no dose adjustment is required; however, if creatinine clearance falls to ≥10 and ≤30 mL/min, reduce initial dose to half the usual recommended dose 3
• Monitor serum creatinine and potassium regularly when using ACE inhibitors, ARBs, or diuretics 1

Blood Pressure Management

• Target systolic blood pressure <120 mm Hg in non-diabetic CKD patients based on SPRINT trial data showing mortality benefit (death HR: 0.72,95% CI 0.53-0.99) 1
• Target blood pressure <130/80 mm Hg in diabetic patients per ACCORD trial findings 1

Metabolic Complications Management

Anemia Evaluation

• Check hemoglobin, ferritin, transferrin saturation, vitamin B12, and folate to assess and manage CKD-related anemia 1, 2

Mineral Bone Disease

• Monitor calcium, phosphorus, parathyroid hormone, and vitamin D levels to manage CKD-mineral bone disease 1, 2

Electrolyte Management

• Implement dietary potassium restriction and discontinue potassium-sparing medications to prevent hyperkalemia 1, 2
• Check serum bicarbonate and consider supplementation if <22 mEq/L for acidosis management 2

Volume Status

• Carefully manage fluid and sodium intake to avoid both volume overload and depletion 2

Dietary Modifications

• Restrict protein intake to approximately 0.8 g/kg body weight per day for non-dialysis CKD patients to slow disease progression 1

Cardiovascular Risk Management

• Aggressively manage cardiovascular risk factors, as CKD Stage 4 markedly increases cardiovascular risk requiring intensified management of hypertension, diabetes, and dyslipidemia 1
• Traditional cardiovascular risk factor management remains important, though cardiovascular pathways in CKD may differ from the general population, with medial arterial calcification playing a larger role 1

Critical Pitfalls to Avoid

• Do not rely on serum creatinine alone to assess kidney function, as creatinine assumes steady-state conditions and can appear falsely normal despite significantly reduced eGFR 4, 1, 5
• In patients with eGFR <60 mL/min/1.73m², serum creatinine values were apparently normal (<1.2 mg/dL in women, <1.4 mg/dL in men) in 54% of cases 6
• Do not delay nephrology referral—permanent damage is likely present at this level of kidney function 1
• Serum creatinine levels depend on patient age, hydration status, and muscular mass, making eGFR assessment essential 4

Ongoing Monitoring

• Evaluate and manage all CKD complications when eGFR <60 mL/min/1.73m², including anemia, bone disease, acidosis, and electrolyte abnormalities 1
• Monitor for progression with regular eGFR measurements and clinical assessment 7