What are the management options for a patient with severely impaired renal function, indicated by an estimated Glomerular Filtration Rate (eGFR) of 13, elevated creatinine levels, increased albuminuria, and uremia, likely with chronic kidney disease stage 5 and potential comorbidities such as hypertension and diabetes?

Management of Stage 5 CKD with eGFR 13, Creatinine 400, Albuminuria, and Uremia

Immediate nephrology referral is mandatory for this patient with eGFR <30 mL/min/1.73 m², and preparation for kidney replacement therapy should begin now. 1

Urgent Nephrology Referral

Refer immediately to nephrology - this is a non-negotiable requirement for eGFR <30 mL/min/1.73 m² 1. The presence of uremic symptoms with eGFR 13 indicates advanced stage 5 CKD requiring specialized management and preparation for dialysis or transplantation 1.

Kidney Replacement Therapy Planning

• Initiate dialysis planning now - with eGFR 13 and uremic symptoms present, this patient is at or near the threshold for dialysis initiation (typically eGFR 10-15 mL/min/1.73 m²) 1
• Evaluate for kidney transplantation - pre-emptive transplantation should be considered before dialysis becomes necessary if the patient is a suitable candidate 1
• Establish vascular access - if hemodialysis is anticipated, arteriovenous fistula creation should occur now to allow maturation (requires 2-3 months) 1
• Consider peritoneal dialysis - evaluate eligibility for home dialysis options, which may be optimal for some patients 1

Blood Pressure Management

• Target BP <130/80 mmHg using ACE inhibitor or ARB if not already prescribed 1
• Continue ACE inhibitor/ARB despite low eGFR - do not discontinue for creatinine increases ≤30% unless volume depletion is present 1
• Monitor serum creatinine and potassium closely - check within 1-2 weeks after any dose adjustment of renin-angiotensin system blockers 1, 2

Albuminuria Reduction

• Target ≥30% reduction in albuminuria to slow CKD progression 1
• Maximize ACE inhibitor or ARB dosing if tolerated, as these agents reduce albuminuria and provide renoprotection 1
• Consider adding finerenone (nonsteroidal mineralocorticoid receptor antagonist) if albuminuria persists despite ACE inhibitor/ARB therapy, to reduce CKD progression and cardiovascular events 1

Glycemic Control (if Diabetic)

• Target HbA1c <7.0% for most patients, but individualize based on hypoglycemia risk and comorbidities 1
• Use HbA1c <8.0% for patients with high hypoglycemia risk, multiple comorbidities, or advanced CKD 1
• Initiate SGLT2 inhibitor if not contraindicated and albuminuria ≥200 mg/g, as these agents slow CKD progression 1, 3
• Adjust medication doses for reduced eGFR - many diabetes medications require dose reduction or discontinuation at this level of kidney function 1

Dietary Management

• Restrict dietary protein to 0.8 g/kg/day maximum - this is the recommended daily allowance for non-dialysis CKD stage 5 1, 3
• Increase protein intake once dialysis starts - higher protein intake (1.0-1.2 g/kg/day) will be needed on dialysis to prevent malnutrition 1
• Restrict potassium, phosphorus, and sodium - specific restrictions depend on laboratory values and should be guided by nephrology and dietitian 1

Anemia Management

• Check complete blood count - anemia is expected at this eGFR level 3
• Evaluate iron stores - measure serum ferritin and transferrin saturation before initiating erythropoiesis-stimulating agents (ESAs) 4
• Administer supplemental iron when ferritin <100 μg/L or transferrin saturation <20% 4
• Initiate ESA therapy (epoetin alfa) if hemoglobin <10 g/dL, starting at 50-100 Units/kg three times weekly 4
• Target hemoglobin 10-11 g/dL - do NOT target >11 g/dL as this increases mortality, myocardial infarction, stroke, and thromboembolism risk 4

Metabolic Complications Management

• Monitor and treat hyperkalemia - check potassium at least monthly, more frequently if on ACE inhibitor/ARB or with dietary indiscretion 1
• Manage metabolic acidosis - check serum bicarbonate and treat if <22 mEq/L with oral sodium bicarbonate 1
• Screen for CKD-mineral bone disorder - check calcium, phosphorus, parathyroid hormone, and vitamin D levels 1
• Manage hyperphosphatemia with phosphate binders if phosphorus elevated 1

Cardiovascular Risk Reduction

• Initiate statin therapy - patients with CKD have markedly increased cardiovascular risk 1
• Consider aspirin for primary prevention if 10-year ASCVD risk >10% 1
• Avoid nephrotoxins - discontinue NSAIDs, aminoglycosides, and other nephrotoxic agents 3

Monitoring Frequency

• Check eGFR and UACR every 1-2 months at this stage of CKD 1
• Monitor electrolytes monthly - particularly potassium, bicarbonate, calcium, and phosphorus 1
• Assess volume status at each visit - adjust diuretic dosing as needed for fluid management 1

Critical Pitfalls to Avoid

• Do not delay nephrology referral - eGFR <30 requires immediate specialist involvement 1
• Do not target hemoglobin >11 g/dL with ESA therapy - this significantly increases mortality and cardiovascular events 4
• Do not discontinue ACE inhibitor/ARB prematurely - creatinine increases up to 30% are acceptable and do not indicate harm 1
• Do not restrict protein excessively - 0.8 g/kg/day is the minimum, not a lower target 1