What are the guidelines for managing a patient with impaired renal function and potential comorbidities, including medication and dietary recommendations?

Guideline Management of Renal Failure

For patients with chronic kidney disease (CKD), management should prioritize blood pressure control with RAAS inhibitors (ACEi/ARB), SGLT2 inhibitors for cardio-renal protection, dietary sodium restriction to <2.3 g/day, protein intake of 0.8 g/kg/day for stages 3-5, and systematic medication dose adjustments based on eGFR. 1

Blood Pressure and RAAS Inhibition

• Initiate ACE inhibitors or ARBs in all CKD patients with hypertension or proteinuria, as these agents reduce microalbuminuria and slow progression to end-stage renal disease 1
• For ramipril, start at 1.25 mg daily when creatinine clearance <30 mL/min, with maximum dose of 5 mg/day 1
• For losartan, use 50-100 mg/day for hypertension or diabetic nephropathy with microalbuminuria, with regular monitoring of electrolytes and serum creatinine 1, 2
• For lisinopril, dose adjustment is required when creatinine clearance ≤30 mL/min or in patients undergoing hemodialysis 3
• Monitor serum creatinine after initiating RAAS inhibitors—an initial increase that returns to baseline is expected and acceptable; discontinue only if creatinine rises >30% and remains elevated 1
• Contraindications include bilateral renal artery stenosis and pregnancy (Category D—discontinue immediately if pregnancy detected) 3

Cardio-Renal Protective Medications

• Prescribe SGLT2 inhibitors for all adults with type 2 diabetes and CKD who have not achieved glycemic targets despite metformin, prioritizing agents with documented cardiovascular and kidney benefits 1
• Add long-acting GLP-1 receptor agonists if glycemic targets remain unmet despite SGLT2 inhibitor use, choosing agents with proven cardiovascular benefits 1
• Initiate statin or statin/ezetimibe combination in all adults ≥50 years with eGFR <60 mL/min/1.73 m² (stages G3a-G5) not on chronic dialysis 1
• For simvastatin, use caution with doses >10 mg when creatinine clearance <30 mL/min due to low renal elimination 1

Dietary Management

Sodium and Fluid

• Restrict sodium to <2.3 g/day (<90 mmol/day or <5 g sodium chloride/day) for all CKD patients to control blood pressure and reduce cardiovascular risk 1, 4, 5
• Sodium restriction is particularly critical when eGFR is reduced, as urinary sodium excretion becomes impaired 1

Protein Intake

• Maintain protein at 0.8 g/kg body weight/day for CKD stages 3-5 to slow progression while preventing malnutrition 1, 4, 6
• Avoid high protein intake >1.3 g/kg/day, as this accelerates albuminuria, kidney function loss, and cardiovascular mortality 1, 4, 6
• For patients at high risk of kidney failure who are metabolically stable and willing, consider very low-protein diet (0.3-0.4 g/kg/day) supplemented with essential amino acids or ketoacid analogs under close supervision 4, 6
• For dialysis patients, increase protein to 1.0-1.2 g/kg/day to prevent malnutrition 6, 1
• Never restrict protein in children with CKD due to growth impairment risk 1

Phosphorus and Potassium

• Restrict phosphorus to 0.8-1.0 g/day when eGFR falls below 60 mL/min (typically stages 3-4) 4
• Limit intake of foods rich in bioavailable potassium (especially processed foods) for CKD G3-G5 patients with history of hyperkalemia 1
• Potassium restriction to 2-4 g/day may be necessary depending on CKD stage and serum levels 1, 4

Energy and Diet Quality

• Ensure adequate energy intake of 25-35 kcal/kg body weight/day to prevent protein-energy wasting 4, 5
• Emphasize plant-based foods over animal-based foods and minimize ultraprocessed foods 1, 4

Implementation

• Refer all CKD patients to renal dietitians or accredited nutrition providers for education about dietary adaptations tailored to sodium, phosphorus, potassium, and protein needs 1, 4, 6

Medication Dosing and Safety

General Principles

• Consider eGFR when dosing all medications cleared by the kidneys 1
• Use validated eGFR equations based on serum creatinine for most drug dosing decisions 1
• For medications with narrow therapeutic windows (e.g., digoxin, aminoglycosides, vancomycin), consider equations combining creatinine and cystatin C, or measured GFR 1
• Monitor eGFR, electrolytes, and therapeutic drug levels in CKD patients receiving medications with narrow therapeutic windows or nephrotoxic potential 1

Specific Medication Adjustments

• Enoxaparin: Contraindicated or requires dose adjustment when creatinine clearance <30 mL/min; consider fondaparinux as safer alternative 1
• Fondaparinux: Contraindicated when creatinine clearance <30 mL/min, though showed lower bleeding risk than enoxaparin in severe renal failure 1
• Bivalirudin: Reduce infusion to 1.0 mg/kg/h when creatinine clearance <30 mL/min; reduce to 0.25 mg/kg/h for hemodialysis patients 1
• Tirofiban: Use 50% dose when creatinine clearance <30 mL/min 1
• Eptifibatide: Reduce infusion to 1 mg/kg/min when creatinine clearance <50 mL/min; contraindicated when <30 mL/min 1
• Atenolol: Use 50 mg/day when creatinine clearance 15-35 mL/min; use 25 mg/day when <15 mL/min 1

Medication Safety

• Review and limit over-the-counter medicines and herbal remedies that may be harmful in CKD 1
• Establish collaborative relationships with pharmacists to ensure drug stewardship and manage complex medication regimens 1
• Educate patients about expected benefits and risks so they can identify and report adverse events 1

Management of Specific Complications

Hyperkalemia

• Be aware of variability in potassium measurements including diurnal/seasonal variation, plasma versus serum samples, and medication effects 1
• Implement individualized approach for CKD G3-G5 with emergent hyperkalemia including dietary and pharmacologic interventions 1
• Steroidal mineralocorticoid receptor antagonists may be used for heart failure or refractory hypertension but can cause hyperkalemia, particularly with low GFR 1

Metabolic Acidosis

• Consider pharmacological treatment with or without dietary intervention to prevent acidosis when serum bicarbonate <18 mmol/L in adults 1
• Monitor treatment to ensure bicarbonate does not exceed upper limit of normal and does not adversely affect blood pressure, potassium, or fluid status 1

Hyperuricemia

• Offer uric acid-lowering intervention for symptomatic hyperuricemia (gout) 1
• Consider initiating therapy after first gout episode, particularly when serum uric acid >9 mg/dL (535 μmol/L) 1
• Prescribe xanthine oxidase inhibitors (allopurinol, febuxostat) in preference to uricosuric agents 1
• For acute gout treatment, use low-dose colchicine or glucocorticoids rather than NSAIDs 1
• Do not use uric acid-lowering agents for asymptomatic hyperuricemia to delay CKD progression 1

Anemia and Metabolic Bone Disease

• Evaluate hemoglobin and iron studies when eGFR <60 mL/min/1.73 m² 1
• Monitor serum calcium, phosphate, PTH, and vitamin 25(OH)D for metabolic bone disease 1

Monitoring and Follow-Up

Frequency Based on Risk

• eGFR ≥60 mL/min with normal albumin-to-creatinine ratio: Annual monitoring 1
• eGFR 45-59 mL/min: At least yearly measurements 1
• eGFR 30-44 mL/min: Twice yearly measurements 1
• eGFR 15-29 mL/min: Three times yearly measurements 1
• eGFR <15 mL/min: Four times yearly measurements 1

Nephrology Referral

• Refer all patients with CKD stages 4-5 (eGFR <30 mL/min) to nephrology 7
• Refer earlier based on rapid progression, severe albuminuria, or early warning signs 7
• Establish protocols for joint follow-up between primary care and nephrology 7

Nutritional Monitoring

• Monitor nutritional status regularly through appetite assessment, dietary intake evaluation, body weight changes, and biochemical markers 4, 6
• Watch for protein-energy wasting, which increases morbidity and mortality 4, 6

Common Pitfalls to Avoid

• Never implement protein restriction without proper nutritional counseling and regular follow-up, as this places patients at serious risk for malnutrition 4, 6, 5
• Do not use fluid-overloaded weight for protein calculations; use adjusted body weight instead 5
• Do not discontinue RAAS inhibitors for initial creatinine increases unless rise is >30% and sustained 1
• Avoid NSAIDs for gout treatment in CKD patients; use colchicine or glucocorticoids instead 1
• Do not prescribe low or very low-protein diets to metabolically unstable patients 6
• Preserve peripheral veins in stage III-V CKD patients for future hemodialysis access 8

Preparation for Kidney Replacement Therapy

• Begin patient education about treatment options when patients reach CKD stage 4 (eGFR <30 mL/min) 1
• Evaluate benefits, risks, and disadvantages of kidney replacement therapy when patients reach stage 5 (eGFR <15 mL/min) 1
• Consider conservative therapy without dialysis for patients with limited life expectancy, severe comorbidities, or who wish to avoid medical interventions 8
• Create multidisciplinary ACKD units including nephrologist, nephrology nurse, dietitian, and social worker for cost-effective integrated care 7

Vaccination Recommendations

• Vaccinate against seasonal influenza, tetanus, hepatitis B, HPV (through age 26), and Streptococcus pneumoniae for all ESRD patients 8
• Routine cancer screening is discouraged for patients not receiving kidney transplantation 8