What is the management plan for a patient with an estimated glomerular filtration rate (EGFR) of 27, indicating severe kidney impairment, likely chronic kidney disease (CKD) stage 4 or end-stage renal disease (ESRD)?

Management of eGFR 27 mL/min/1.73 m²

A patient with eGFR 27 requires immediate nephrology referral, as this represents Stage 4 CKD (severe kidney impairment) and mandates specialist co-management to prepare for potential renal replacement therapy and manage complex complications. 1, 2

Immediate Nephrology Referral

• All patients with eGFR <30 mL/min/1.73 m² must be referred to nephrology immediately, as consultation at this stage reduces costs, improves quality of care, and delays dialysis initiation. 1, 2, 3
• Late referral is associated with increased mortality after dialysis initiation, making timely specialist involvement critical. 1
• Begin structured education about dialysis and transplantation options now, as preparation takes months and progression rates are unpredictable. 2, 3

Blood Pressure Management

• Target systolic blood pressure <120 mmHg when tolerated using standardized office measurement. 2, 3
• Start an ACE inhibitor or ARB as first-line therapy for blood pressure control and proteinuria reduction, titrated to maximum tolerated dose. 1, 2, 3
• Monitor serum creatinine and potassium within 2-4 weeks of initiation or dose increase. 3
• Continue ACE inhibitor/ARB unless creatinine rises >30% within 4 weeks of starting therapy. 3
• Never combine ACE inhibitor with ARB due to increased risk of hyperkalemia and acute kidney injury. 1, 3
• Use loop diuretics (not thiazides) for volume control in patients with fluid overload. 3
• Restrict dietary sodium to <2 g/day to enhance blood pressure control and reduce hyperfiltration injury. 4, 3

Diabetes Management (if applicable)

• Start an SGLT2 inhibitor if the patient has type 2 diabetes, as eGFR 27 is above the initiation threshold of ≥20 mL/min/1.73 m². 2, 3
• Continue SGLT2 inhibitor even if eGFR falls below 20 mL/min/1.73 m² unless not tolerated or dialysis initiated. 3
• Reduce metformin dose to 1000 mg daily or discontinue, as eGFR 27 is below the safe threshold of 30 mL/min/1.73 m². 2
• Use glipizide as preferred sulfonylurea due to lack of active metabolites. 3
• Consider DPP-4 inhibitors (sitagliptin, saxagliptin, linagliptin) with appropriate dose adjustments. 3
• Target A1C of 7% to delay CKD progression. 4

Cardiovascular Risk Reduction

• Start a moderate-intensity statin for primary prevention or high-intensity statin if the patient has known atherosclerotic cardiovascular disease. 2, 3
• Consider PCSK-9 inhibitors for patients who have an indication for their use. 3
• Use oral low-dose aspirin for secondary prevention in patients with established ischemic cardiovascular disease. 3

Monitoring for CKD Complications

Mineral and Bone Disorder

• Monitor serum calcium and phosphorus every 3-6 months. 4, 3
• Monitor PTH every 6-12 months. 4, 3
• Measure alkaline phosphatase annually or more frequently if PTH elevated. 3
• Measure 25(OH)D levels and correct deficiency using general population treatment strategies. 3

Anemia

• Perform complete blood count at least monthly after initial stabilization. 3
• Assess and treat anemia by removing underlying causes and using standard CKD measures. 3

Metabolic Monitoring

• Screen for electrolyte abnormalities, metabolic acidosis, hyperkalemia, and volume status every 6-12 months. 4, 3
• Manage hyperkalemia with dietary restriction and potassium binders rather than immediately discontinuing ACE inhibitor/ARB. 3

Medication Safety and Adjustments

• Verify dosing of all medications, as many require adjustment when eGFR <60 mL/min/1.73 m². 4
• Strictly avoid NSAIDs and COX-2 inhibitors, as they reduce renal blood flow and can precipitate acute kidney injury. 4, 3, 5
• Avoid iodinated contrast media. 3
• For opioid pain management, fentanyl and buprenorphine (transdermal or intravenous) are the safest choices in CKD stage 4. 1

Dietary Modifications

• Limit dietary protein to approximately 0.8 g/kg body weight per day to reduce hyperfiltration injury and slow progression. 4, 3
• A plant-based "Mediterranean-style" diet may be considered to reduce cardiovascular risk. 3

Preparation for Renal Replacement Therapy

• Begin structured pre-dialysis education program to allow time for decision-making and access creation. 3
• Evaluate for preemptive kidney transplantation including living donor assessment. 3
• Create arteriovenous fistula in advance for patients likely to require hemodialysis, as maturation takes weeks to months. 2, 3
• For patients interested in peritoneal dialysis, delay AVF creation and focus on PD catheter planning. 3
• Hepatitis B vaccination is indicated early in patients likely to progress to end-stage kidney disease. 4

Urgent Indications for Dialysis Initiation

Refer urgently if the patient develops: 2, 3

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

Follow-up Schedule

• Measure eGFR and urine albumin-to-creatinine ratio (UACR) at least annually. 4
• Check serum creatinine, potassium, and blood pressure within 2-4 weeks of starting ACE inhibitor/ARB. 3
• Laboratory monitoring for complications every 6-12 months for Stage 4 CKD. 4

Critical Pitfalls to Avoid

• Do not delay nephrology referral, as late referral is associated with increased mortality. 1
• Do not overlook cardiovascular risk, as CKD at this stage markedly increases cardiovascular disease risk requiring aggressive risk factor modification. 4, 3, 5
• Do not use thiazide diuretics for volume control; loop diuretics are required at this level of kidney function. 3
• Do not combine ACE inhibitors with ARBs. 1, 3