What are the management and treatment recommendations for a patient with moderate to severe kidney impairment, indicated by an estimated Glomerular Filtration Rate (eGFR) of 30?

Management of eGFR 30 mL/min/1.73 m²

Patients with eGFR 30 mL/min/1.73 m² have Stage 4 chronic kidney disease and require immediate nephrology referral, careful medication adjustments, and preparation for potential renal replacement therapy. 1

Immediate Actions

Nephrology Referral

• Refer immediately to nephrology if not already established. Consultation at eGFR <30 mL/min/1.73 m² reduces costs, improves quality of care, and delays dialysis. 1
• The Canadian Society of Nephrology recommends formal referral for GFR <30 mL/min/1.73 m² unless the finding is stable and isolated with clear diagnosis in elderly patients with limited life expectancy. 1

Monitoring Frequency

• Monitor creatinine, eGFR, urinary albumin excretion, and potassium twice yearly as baseline for Stage 4 CKD. 1
• Increase monitoring to quarterly or more often if rapid progression occurs, new medications are initiated, or clinical status changes. 1
• When administering IV fluids, monitor electrolytes and renal function daily due to significantly increased risk of fluid overload and further kidney damage. 2

Critical Medication Adjustments

Medications to DISCONTINUE Immediately

• Metformin: Contraindicated at eGFR <30 mL/min/1.73 m²—discontinue immediately. 1, 3
• Nitrofurantoin: Avoid use. 3
• Exenatide: Contraindicated. 1
• Glyburide: Avoid use. 1

Medications Requiring Dose Reduction

• Insulin: Reduce total daily dose by 35-50% due to decreased renal clearance and reduced gluconeogenesis. 1
• Gabapentin and Pregabalin: Require dose adjustment (expert consensus identifies these as top priority medications). 3
• Ciprofloxacin: Requires dose adjustment. 3
• Rivaroxaban: Requires dose adjustment or avoidance. 3
• Fenofibrate: Do not exceed 54 mg/day if eGFR is between 30-59 mL/min/1.73 m²; discontinue if eGFR persistently <30 mL/min/1.73 m². 4

SGLT2 Inhibitors

• Canagliflozin: Maximum 100 mg daily; may continue for kidney and cardiovascular benefit until dialysis. 1
• Dapagliflozin: Not recommended for glucose lowering at eGFR <45, but may be used at 10 mg for heart failure or CKD indications if eGFR is 25-45. 1

DPP-4 Inhibitors (Require Dose Reduction)

• Sitagliptin: 25 mg daily. 1
• Alogliptin: 6.25 mg daily. 1
• Saxagliptin: Maximum 2.5 mg daily if eGFR ≤45 mL/min/1.73 m². 1

GLP-1 Receptor Agonists

• Lixisenatide: Avoid if eGFR <15 mL/min/1.73 m². 1
• Liraglutide, dulaglutide, and semaglutide: No dose adjustment required but monitor eGFR when initiating or escalating doses. 1

Anticoagulants

• NSAIDs: Avoid use (expert consensus identifies as top priority). 3
• Low-molecular weight heparins, danaparoid, hirudins, and bivalirudin all undergo renal clearance and require lower doses with closer monitoring. 5
• Fondaparinux should be avoided in severe renal impairment. 5
• Unfractionated heparin and warfarin generally do not require dose adjustment, though smaller warfarin doses may be needed to achieve target INR. 5

Blood Pressure Management

• Target systolic BP <130 mmHg and diastolic BP <80 mmHg. 1, 6
• Use ACE inhibitors or ARBs as first-line agents for blood pressure control and kidney protection. 1, 6
• Do not routinely discontinue ACE-I/ARB at eGFR <30—continue with careful monitoring of renal function and potassium. 6

Fluid Management Precautions

• Consult nephrology before administering IV fluids to patients with eGFR 30, as they are at significantly increased risk of fluid overload and further kidney damage. 2, 1
• Monitor daily for signs of fluid overload when IV fluids are necessary. 2, 1
• Consider more frequent monitoring of renal function in patients requiring volume expansion. 2

Screening for CKD Complications

• Screen for and manage secondary hyperparathyroidism as part of CKD-mineral bone disease management. 1
• Evaluate and correct metabolic acidosis, which commonly develops at this level of kidney function. 1

Glycemic Management (if diabetic)

• Target HbA1c <7.0% for most patients, though higher targets may be appropriate for those with severe comorbidities, limited life expectancy, or high hypoglycemia risk. 1
• Monitor HbA1c twice yearly, increasing to quarterly if not at target or therapy changes. 1

Preparation for Renal Replacement Therapy

• Begin patient education about the progressive nature of kidney disease and potential need for dialysis or transplantation. 1
• Discuss options for renal replacement therapy and consider vascular access planning. 1
• Dialysis initiation should be considered when GFR falls below 15 mL/min/1.73 m², though certain complications may justify earlier initiation. 1
• It may be optimal to perform kidney transplantation or begin home dialysis before patients reach CKD stage 5 (GFR <15). 1

Common Pitfalls to Avoid

• Do not rely solely on eGFR for drug dosing decisions in patients with unusual creatinine generation or altered tubular secretion, as eGFR may not accurately predict proximal tubule drug handling. 7
• Do not assume all medications are equally affected by renal impairment—cationic secretion correlates poorly with GFR (R² = 0.11), while anionic transport correlates moderately (R² = 0.40-0.44). 7
• Do not initiate dialysis based on GFR alone—dialysis must be driven by clinical symptoms such as uremic symptoms, volume overload refractory to diuretics, uncontrolled hypertension, or severe metabolic derangements. 6
• Patients with CKD are less likely to be prescribed, fill prescriptions for, adhere to, and persist on evidence-based therapies, even at eGFR categories where these therapies are recommended and have shown efficacy. 8