What is the appropriate management for a patient with a Glomerular Filtration Rate (GFR) of 60 mL/min, indicating impaired renal function?

Management of GFR 60 mL/min/1.73 m²

A patient with a GFR of 60 mL/min/1.73 m² has Stage 3a chronic kidney disease (CKD) and requires immediate assessment of albuminuria, blood pressure optimization, evaluation for diabetes, and initiation of nephroprotective strategies to prevent progression. 1

Immediate Diagnostic Assessment

Obtain a spot urine albumin-to-creatinine ratio (ACR) immediately to stratify cardiovascular and renal risk, as this is the single most important prognostic factor at this GFR level. 1, 2

• Normal ACR is <30 mg/g, microalbuminuria is 30-299 mg/g, and macroalbuminuria is ≥300 mg/g 2
• If abnormal, confirm with 2 of 3 specimens collected within 3-6 months, as exercise, infection, fever, heart failure, marked hyperglycemia, and marked hypertension can transiently elevate albumin excretion 2
• Patients with ACR ≥300 mg/g or eGFR 30-60 mL/min/1.73 m² should be monitored twice annually to guide therapy 1

Blood Pressure Management

Target blood pressure <140/90 mmHg as the standard goal for all patients with Stage 3a CKD. 2

• Consider more intensive control (systolic <120 mmHg) if additional cardiovascular risk factors are present, based on SPRINT trial data showing reduced cardiovascular events and mortality in non-diabetic CKD patients 2
• Initiate an ACE inhibitor or ARB if albuminuria is present (ACR ≥30 mg/g) AND the patient is hypertensive 1, 2
• Do not discontinue renin-angiotensin system blockade for minor increases in serum creatinine (≤30%) in the absence of volume depletion 1
• Monitor serum potassium regularly in patients on ACE inhibitors or ARBs, as these medications can cause hyperkalemia associated with cardiovascular risk and mortality 1

Diabetes-Specific Management (if applicable)

Optimize glucose control with HbA1c target <7% to reduce the risk or slow the progression of CKD. 1

• For patients with type 2 diabetes and albuminuria ≥200 mg/g creatinine, initiate an SGLT2 inhibitor to reduce CKD progression and cardiovascular events 1
• SGLT2 inhibitors are recommended for patients with eGFR ≥20 mL/min/1.73 m² and urinary albumin ≥200 mg/g creatinine 1
• For patients with diabetes and albuminuria ranging from normal to 200 mg/g creatinine, SGLT2 inhibitors are also recommended 1
• In patients with CKD who are at increased risk for cardiovascular events or CKD progression or are unable to use an SGLT2 inhibitor, consider finerenone (a nonsteroidal mineralocorticoid receptor antagonist) 1

Medication Dosing Adjustments at GFR 60 mL/min/1.73 m²

Metformin can be continued at GFR 60 mL/min/1.73 m² but requires careful monitoring. 3

• Metformin is contraindicated when eGFR falls below 30 mL/min/1.73 m² 3
• Initiation of metformin is not recommended when eGFR is between 30-45 mL/min/1.73 m² 3
• Assess benefit-risk if eGFR falls below 45 mL/min/1.73 m² in patients already taking metformin 3
• Discontinue metformin at the time of, or prior to, iodinated contrast imaging procedures in patients with eGFR between 30-60 mL/min/1.73 m²; re-evaluate eGFR 48 hours after the procedure 3

Other diabetes medication adjustments at GFR 60 mL/min/1.73 m²: 1

• Sitagliptin: 100 mg daily (no adjustment needed at GFR >50 mL/min/1.73 m²) 1
• Saxagliptin: No dose adjustment needed at GFR ≥45 mL/min/1.73 m² 1
• Alogliptin: 25 mg daily (no adjustment needed at GFR >60 mL/min/1.73 m²) 1
• Linagliptin: No dose adjustment needed 1
• GLP-1 receptor agonists (liraglutide, dulaglutide, semaglutide): No dose adjustment needed, but monitor for gastrointestinal reactions 1
• SGLT2 inhibitors: Dapagliflozin should not be initiated at GFR <60 mL/min/1.73 m²; canagliflozin requires no adjustment at GFR ≥60 mL/min/1.73 m²; empagliflozin requires no adjustment at GFR ≥45 mL/min/1.73 m² 1

Dietary Modifications

Restrict dietary protein intake to 0.8 g/kg body weight per day (the recommended daily allowance) for patients with nondialysis-dependent Stage 3 CKD. 1

• Avoid protein intake <0.6 g/kg/day due to safety concerns and risk of malnutrition 1
• Emphasize vegetable (plant) sources of protein 1
• Restrict dietary sodium to <2.0 g/day (<90 mmol/day) to reduce edema, control blood pressure, and control proteinuria 1
• Target caloric intake of 30-35 kcal/kg/day for patients with eGFR <60 mL/min/1.73 m² 1
• Restrict dietary fats to <30% of total calories, with mono- or polyunsaturated fat comprising 7-10% of total calories, in patients with elevated serum cholesterol 1

Monitoring Schedule

Check serum creatinine and eGFR at least annually for stable Stage 3a CKD. 1, 2

• Measure urine albumin-to-creatinine ratio at least once yearly 1, 2
• Monitor serum potassium regularly, especially in patients on ACE inhibitors, ARBs, or diuretics 1
• Screen for CKD complications when eGFR is <60 mL/min/1.73 m², including anemia, metabolic bone disease, and metabolic acidosis 1
• Verify appropriate medication dosing and minimize exposure to nephrotoxins (e.g., NSAIDs and iodinated contrast) 1

Nephrology Referral Criteria

Refer to nephrology if any of the following occur: 1, 2, 4

• eGFR declines to <30 mL/min/1.73 m² 1, 2, 4
• Rapid GFR decline (>5 mL/min/1.73 m²/year) 2
• Significant albuminuria develops (ACR ≥300 mg/g) 2
• Uncertainty exists about the etiology of kidney disease (heavy proteinuria, active urine sediment, absence of retinopathy, rapid decline in GFR) 1
• Refractory hypertension requiring ≥4 antihypertensive agents 2
• Persistent hyperkalemia or other difficult management issues (anemia, secondary hyperparathyroidism, metabolic bone disease, electrolyte disturbances) 1, 2

Cardiovascular Risk Assessment

Assess cardiovascular risk and commence appropriate interventions, as CKD markedly increases cardiovascular risk. 1

• Provide lifestyle advice including dietary sodium restriction, smoking cessation, weight control, and exercise 1
• Optimize blood pressure control and reduce blood pressure variability to slow CKD progression 1
• Consider statin therapy for cardiovascular risk reduction, as patients with CKD have elevated cardiovascular mortality 1

Common Pitfalls to Avoid

• Do not assume GFR 60 mL/min/1.73 m² is "normal" – while this may be at the lower end of normal for elderly patients, it represents Stage 3a CKD and requires evaluation for kidney damage markers (albuminuria) and risk stratification 5, 6, 7
• Do not discontinue ACE inhibitors or ARBs for minor creatinine increases (≤30%) unless volume depletion is present 1
• Do not prescribe bisphosphonates without caution – while not contraindicated at GFR 60 mL/min/1.73 m², zoledronic acid requires dose reduction when GFR <60 mL/min/1.73 m² 8
• Do not overlook the need for twice-yearly monitoring if the patient has both eGFR 30-60 mL/min/1.73 m² AND albuminuria ≥300 mg/g 1