From the Guidelines
The probability that a 62-year-old man with one kidney and an eGFR of 27 will need dialysis is moderately high, though not immediate, with approximately 20-40% of patients with Stage 4 CKD progressing to kidney failure requiring dialysis within 5 years. With an eGFR of 27 ml/min/1.73m², this patient has Stage 4 chronic kidney disease (CKD), which represents severe kidney damage with significantly reduced function [ 1 ]. Having a single kidney adds additional risk. According to the clinical practice guidelines for hemodialysis adequacy, update 2006, initiation of kidney replacement therapy should be considered when GFR decreases to less than 15 mL/min/1.73 m2, unless there are specific indications to initiate dialysis therapy [ 1 ].
Key Considerations
- The patient should be closely monitored with regular nephrology visits every 2-3 months.
- Blood pressure control targeting less than 130/80 mmHg is crucial.
- Medication management including ACE inhibitors or ARBs if appropriate should be considered.
- Dietary modifications are essential, including:
- Sodium restriction to 2-3 grams daily.
- Moderate protein intake (0.8 g/kg/day).
- Potassium and phosphorus restrictions as needed.
Factors Influencing Progression to Dialysis
- Blood pressure control.
- Presence of diabetes.
- Proteinuria levels.
- Rate of eGFR decline. If the eGFR is stable or declining slowly (less than 3 ml/min/year), dialysis might be delayed for many years or potentially avoided [ 1 ]. The patient should avoid nephrotoxic medications like NSAIDs and certain antibiotics to slow the progression of kidney disease.
From the Research
Probability of Needing Dialysis
The probability of a 62-year-old man with one kidney and an eGFR of 27 needing dialysis is influenced by several factors, including his overall health, presence of comorbidities, and the rate of decline in his kidney function.
- The study 2 suggests that the decision to start dialysis should not be based solely on estimated GFR (eGFR), but rather on the presence of symptoms and signs of end-stage kidney disease.
- According to 2, early dialysis initiation (at an eGFR > 10 mL/min/1.73 m2) is not associated with a morbidity and mortality benefit, and dialysis may be safely delayed until the eGFR is at least as low as 5-7 mL/min/1.73 m2 in asymptomatic patients with careful clinical follow-up and adequate patient education.
- The study 3 found that a more pronounced short-term increase in single-kidney GFR after unilateral nephrectomy is associated with a lower long-term risk of estimated GFR decline, but this study does not directly address the probability of needing dialysis for a patient with an eGFR of 27.
Factors Influencing the Need for Dialysis
Several factors can influence the need for dialysis in a patient with one kidney and an eGFR of 27, including:
- The rate of decline in kidney function: A faster decline in eGFR may indicate a higher likelihood of needing dialysis sooner 2.
- Presence of comorbidities: Patients with comorbidities such as heart failure, diabetes, or hypertension may be at higher risk for needing dialysis 4, 2.
- Age and overall health: Older patients or those with significant comorbidities may be at higher risk for needing dialysis, but may also be more likely to experience adverse effects from dialysis 2.
Renal Function and ACE Inhibitors
The use of ACE inhibitors may have both beneficial and adverse effects on renal function, as discussed in 4.
- ACE inhibitors can reduce proteinuria and slow the progression of renal disease in patients with diabetic and non-diabetic renal disease.
- However, ACE inhibitors can also induce acute renal failure in certain patients, particularly those with heart failure or severe depletion of circulating volume.