What is the recommended treatment plan for a patient with Chronic Kidney Disease (CKD) stage 4T?

Management of CKD Stage 4

Patients with CKD Stage 4 (GFR 15-29 mL/min/1.73 m²) require immediate nephrology referral, aggressive management of complications, and preparation for renal replacement therapy. 1

Immediate Nephrology Referral

• Refer all CKD Stage 4 patients to nephrology immediately, as this improves outcomes, reduces costs, and allows timely preparation for dialysis or transplantation 1
• Begin structured pre-dialysis education when Stage 4 is reached, as progression rates are unpredictable and preparation takes months 1
• Evaluate for preemptive kidney transplantation, including living donor assessment 1

Blood Pressure Management

Target and Monitoring

• Target systolic blood pressure <120 mmHg when tolerated using standardized office measurement 1
• Hypertension prevalence approaches 80% in Stage 4 CKD and requires aggressive management 2
• Monitor blood pressure regularly, preferably using 24-hour ambulatory devices 3

Pharmacotherapy

• Start ACE inhibitor or ARB as first-line therapy for blood pressure control and proteinuria reduction 1
• Monitor serum creatinine and potassium within 2-4 weeks of initiation or dose increase 1
• Continue ACE inhibitor/ARB unless creatinine rises >30% within 4 weeks of starting therapy 1
• Never combine ACE inhibitor with ARB due to increased risk of hyperkalemia and acute kidney injury 1
• Manage hyperkalemia with dietary restriction and potassium binders rather than immediately discontinuing ACE inhibitor/ARB 1
• Add dihydropyridine calcium channel blockers and/or loop diuretics (not thiazides) if needed to achieve blood pressure targets 1

Slowing Disease Progression

• Reduce proteinuria/albuminuria as a primary treatment goal using ACE inhibitors or ARBs, as target reduction correlates directly with slowing CKD progression 1, 4
• Restrict dietary sodium to <2g per day to enhance blood pressure control 1
• Avoid nephrotoxic agents including NSAIDs, COX-2 inhibitors, and contrast media 1, 5

Diabetes Management (if applicable)

• Start SGLT2 inhibitor if patient has type 2 diabetes and eGFR ≥20 mL/min/1.73 m² 1
• Continue SGLT2 inhibitor even if eGFR falls below 20 mL/min/1.73 m² unless not tolerated or dialysis initiated 1
• Use glipizide as preferred sulfonylurea due to lack of active metabolites 1
• Consider DPP-4 inhibitors (sitagliptin, saxagliptin, linagliptin) with appropriate dose adjustments 1
• Insulin requires careful dose adjustment due to reduced renal clearance 1

Cardiovascular Risk Reduction

Lipid Management

• For adults aged ≥50 years, treat with a statin or statin/ezetimibe combination 2
• Choose statin-based regimens to maximize absolute reduction in LDL cholesterol 2
• Consider PCSK-9 inhibitors for patients with CKD who have an indication for their use 2
• Consider a plant-based "Mediterranean-style" diet in addition to lipid-modifying therapy 2

Antiplatelet Therapy

• Use oral low-dose aspirin for secondary prevention in patients with established ischemic cardiovascular disease 2
• Consider other antiplatelet therapy (e.g., P2Y12 inhibitors) when there is aspirin intolerance 2

Monitoring and Managing Complications

Mineral and Bone Disorder

• Monitor serum calcium and phosphorus every 3-6 months 1
• Monitor PTH every 6-12 months 1
• Measure alkaline phosphatase annually or more frequently if PTH elevated 1
• Measure 25(OH)D levels and correct deficiency using general population treatment strategies 1

Anemia

• Perform complete blood count at least monthly after initial stabilization 1
• Assess and treat anemia by removing underlying causes and using standard CKD measures 1, 6
• Evaluate iron status before and during treatment; administer supplemental iron when serum ferritin <100 mcg/L or transferrin saturation <20% 7
• Initiate erythropoiesis-stimulating agents (ESAs) when hemoglobin <10 g/dL, using the lowest dose sufficient to reduce need for RBC transfusions 7
• Monitor hemoglobin weekly until stable after initiating or adjusting ESA therapy 7
• Do not target hemoglobin >11 g/dL, as higher targets increase risks of death, serious cardiovascular reactions, and stroke 7

Metabolic Monitoring

• Monitor regularly for hyperkalemia, metabolic acidosis, and electrolyte abnormalities 1, 5, 8
• Supplementation with sodium bicarbonate may retard progression to end-stage renal disease 9

Cardiovascular Disease

• Monitor for cardiovascular disease, as CKD patients have markedly elevated cardiovascular mortality 1, 5

Preparation for Renal Replacement Therapy

Patient Education

• Begin structured pre-dialysis education program when Stage 4 is reached to allow time for decision-making and access creation 1
• Education should include patient, family members, and primary care providers 1
• Discuss all renal replacement options: hemodialysis, peritoneal dialysis, and transplantation 1

Vascular Access Planning

• Create arteriovenous fistula in advance for patients likely to require hemodialysis, recognizing that maturation may take weeks to months 1
• For patients interested in peritoneal dialysis, delay AVF creation and focus on PD catheter planning 1

Medication Management

• Review all medications for appropriate dosing in CKD 1, 5
• Adjust doses of many antibiotics and oral hypoglycemic agents based on kidney function 5
• Avoid allopurinol in patients receiving azathioprine 1

Indications for Urgent Dialysis Initiation

Refer urgently for dialysis if any of the following develop: 1

• Uremic symptoms (nausea, vomiting, altered mental status, pericarditis)
• BUN >100 mg/dL
• Refractory volume overload
• Severe hyperkalemia unresponsive to medical management
• Uremic encephalopathy
• Severe metabolic acidosis (pH <7.2)

Follow-up Schedule

• Check serum creatinine, potassium, and blood pressure within 2-4 weeks of starting ACE inhibitor/ARB 1
• Monitor hemoglobin weekly until stable after ESA initiation or dose adjustment 7
• Perform regular monitoring of mineral metabolism, anemia, and metabolic parameters as outlined above 1

Common Pitfalls to Avoid

• Do not discontinue ACE inhibitors/ARBs prematurely due to initial creatinine elevation (up to 30% increase can be acceptable) 1
• Do not target hemoglobin levels >11 g/dL with ESA therapy, as this increases mortality and cardiovascular risks 7
• Do not delay nephrology referral, as early referral improves outcomes and allows adequate preparation time 1
• Do not use thiazide diuretics for volume control; use loop diuretics instead 1