How should I manage an 82‑year‑old woman with stage 3b chronic kidney disease (estimated glomerular filtration rate 34 mL/min/1.73 m²), mild anemia (hemoglobin 10.9 g/dL), slightly elevated hemoglobin A1c (7.1 %) and fasting glucose (104 mg/dL), who was recently hospitalized for a urinary‑tract infection and is now seen for follow‑up?

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Last updated: February 8, 2026 • View editorial policy

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Management of an 82-Year-Old Woman with Stage 3b CKD, Mild Anemia, and Recent UTI

Immediate Post-UTI Assessment and Monitoring

Your first priority is to confirm complete resolution of the UTI and assess for fluctuating kidney function, as her eGFR has varied significantly (23 → 36 → 34 mL/min/1.73 m²) over recent months. 1

  • Verify UTI resolution: Confirm she has no residual dysuria, frequency, urgency, fever, or costovertebral angle tenderness—if any of these symptoms persist, obtain a properly collected urine specimen for culture before assuming the infection has cleared. 1, 2
  • Repeat renal function in 2–4 weeks: The recent hospitalization and UTI may have caused acute-on-chronic kidney injury; reassess eGFR and creatinine after full recovery to establish her true baseline kidney function. 3
  • Obtain urinalysis with microscopy: Check for persistent pyuria, hematuria, or proteinuria that might indicate ongoing inflammation or incomplete treatment. 2, 4

Chronic Kidney Disease Management (eGFR 34 mL/min/1.73 m² = Stage 3b)

1. Nephrotoxin Avoidance and Medication Review

Immediately review all current medications for nephrotoxic agents and drugs requiring dose adjustment at eGFR 34 mL/min/1.73 m². 2, 3

  • Discontinue or avoid: NSAIDs (including over-the-counter ibuprofen/naproxen), proton pump inhibitors if not essential, aminoglycosides, and contrast dye unless absolutely necessary. 3
  • Adjust doses: Many antibiotics (if future UTI occurs), oral hypoglycemics, and other renally cleared medications require reduction at this eGFR. 2
  • Avoid metformin initiation: With eGFR 34 mL/min/1.73 m², initiating metformin is not recommended per FDA labeling; if she is already taking metformin, assess benefit-risk and consider discontinuation if eGFR falls below 30 mL/min/1.73 m². 5

2. Albuminuria Assessment and Blood Pressure Control

Measure urine albumin-to-creatinine ratio (UACR) if not already done, as her current result of 23 mg/g creatinine is within normal range (<30 mg/g), which is favorable. 3, 6, 7

  • If UACR remains <30 mg/g: Continue monitoring every 6–12 months; no ACE inhibitor or ARB is mandated solely for albuminuria at this level. 3
  • Blood pressure target: Aim for <130/80 mmHg to slow CKD progression and reduce cardiovascular risk; use ACE inhibitors or ARBs as first-line agents if hypertension is present. 3

3. Cardiovascular Risk Reduction

Initiate or continue statin therapy regardless of baseline LDL cholesterol, as CKD stage 3b confers high cardiovascular risk. 3

  • Statin dosing: Moderate-intensity statin (e.g., atorvastatin 10–20 mg daily) is appropriate; no dose adjustment needed for eGFR 34 mL/min/1.73 m². 3

4. Monitoring for CKD Complications

Check serum potassium, bicarbonate, phosphate, calcium, parathyroid hormone (PTH), and 25-hydroxyvitamin D levels now, then every 3–6 months. 3

  • Metabolic acidosis (bicarbonate <22 mmol/L): Her current bicarbonate is 23 mmol/L (normal); if it falls, consider sodium bicarbonate supplementation to slow CKD progression. 3
  • Hyperkalemia: Her potassium is 4.6 mmol/L (normal); avoid potassium-sparing diuretics and high-potassium foods if it rises. 3
  • Secondary hyperparathyroidism: Check PTH and vitamin D; supplement vitamin D if deficient and consider phosphate binders if hyperphosphatemia develops. 3

Anemia Management (Hemoglobin 10.9 g/dL)

Her mild anemia (Hgb 10.9 g/dL, just below the lower limit of 11.1 g/dL) is likely multifactorial—CKD-related erythropoietin deficiency, recent infection, and possible iron deficiency. 1

1. Initial Anemia Workup

Obtain the following tests to determine the cause and guide treatment: 1

  • Complete blood count with differential and platelets (already done—shows normocytic anemia with MCV 86 fL, normal RDW 13.9%).
  • Absolute reticulocyte count: Assess bone marrow response.
  • Serum ferritin and transferrin saturation (TSAT): Iron deficiency is the most common treatable cause of anemia in CKD. 1
  • Serum vitamin B12 and folate levels: Rule out nutritional deficiencies. 1

2. Iron Supplementation if Deficient

If ferritin <100 ng/mL or TSAT <20%, initiate iron therapy before considering erythropoiesis-stimulating agents (ESAs). 1

  • Oral iron: Ferrous sulfate 325 mg once daily is first-line if tolerated; however, absorption is poor in CKD. 1
  • Intravenous iron: If oral iron is not tolerated or ineffective after 3 months, consider IV iron (e.g., iron sucrose 200 mg weekly for 3 weeks). 1

3. ESA Therapy Consideration

Do not initiate ESA therapy unless: 1

  • Hemoglobin falls below 10.0 g/dL despite correcting iron deficiency. 1
  • She has symptomatic anemia (fatigue, dyspnea on exertion) that impairs quality of life. 1
  • She has no history of malignancy or stroke (ESAs are contraindicated in these settings). 1

If ESA therapy is started, target hemoglobin 10–11.5 g/dL (not >11.5 g/dL) to minimize cardiovascular risks. 1

Diabetes Management (HbA1c 7.1%, Fasting Glucose 104 mg/dL)

Her glycemic control is acceptable (HbA1c 7.1%) but requires cautious interpretation at eGFR 34 mL/min/1.73 m², as HbA1c may underestimate true glycemia in advanced CKD due to anemia and altered red cell turnover. 8

1. Glycemic Monitoring Strategy

  • HbA1c remains valid at eGFR 34 mL/min/1.73 m² but becomes less reliable if eGFR falls below 30 mL/min/1.73 m² or if hemoglobin drops further. 8
  • Consider glycated albumin (GA) if HbA1c becomes unreliable (e.g., if eGFR falls below 30 mL/min/1.73 m² or serum albumin drops below 3.5 g/dL). 8
  • Target HbA1c 7.0–7.5% in an 82-year-old with CKD to balance glycemic control against hypoglycemia risk. 8

2. Medication Adjustments

  • Avoid metformin initiation at eGFR 34 mL/min/1.73 m²; if already on metformin, reassess benefit-risk and discontinue if eGFR falls below 30 mL/min/1.73 m². 5
  • Preferred agents: DPP-4 inhibitors (dose-adjust for CKD), GLP-1 receptor agonists (if tolerated), or insulin (no dose adjustment needed). 5
  • Avoid sulfonylureas (risk of hypoglycemia) and SGLT2 inhibitors (less effective at eGFR <30 mL/min/1.73 m²). 5

Nephrologist Referral Criteria

Refer to nephrology now if any of the following apply: 3

  • eGFR <30 mL/min/1.73 m² (she is at 34 mL/min/1.73 m², close to this threshold).
  • Rapid decline in eGFR (>5 mL/min/1.73 m² per year or >10 mL/min/1.73 m² over 5 years)—her fluctuation from 36 → 23 → 34 mL/min/1.73 m² warrants evaluation. 3
  • Albuminuria ≥300 mg/24 hours (UACR ≥300 mg/g)—not present in this case. 3
  • Uncontrolled hypertension despite multiple agents. 3
  • Recurrent UTIs or structural urinary abnormalities. 1, 9

Given her eGFR fluctuation and proximity to stage 4 CKD, refer to nephrology for co-management and preparation for potential renal replacement therapy. 3

UTI Prevention Strategies

Recurrent UTIs are common in older women and accelerate CKD progression; implement preventive measures. 1, 9

  • Avoid indwelling catheters unless absolutely necessary; if used, remove as soon as possible. 1, 9
  • Adequate hydration: Encourage fluid intake (unless contraindicated by heart failure) to maintain urine output. 1, 9
  • Vaginal estrogen therapy: Consider topical estrogen cream if postmenopausal and recurrent UTIs occur. 1
  • Cranberry products or D-mannose: Weak evidence but low harm; may reduce recurrence in some patients. 1
  • Antibiotic prophylaxis: Reserve for ≥3 UTIs per year; use nitrofurantoin 50 mg daily or trimethoprim-sulfamethoxazole 40/200 mg daily (adjust for renal function). 1, 2

Follow-Up Schedule

Establish a structured monitoring plan to detect CKD progression and complications early: 3

  • Renal function (eGFR, creatinine): Every 3 months given stage 3b CKD and recent fluctuation. 3
  • Urinalysis and UACR: Every 6–12 months. 3, 6, 7
  • Hemoglobin and iron studies: Every 3–6 months until anemia is stable. 1
  • HbA1c: Every 3 months. 8
  • Electrolytes, bicarbonate, phosphate, calcium, PTH, vitamin D: Every 3–6 months. 3
  • Blood pressure: At every visit; home monitoring if feasible. 3

Critical Pitfalls to Avoid

  • Do not treat asymptomatic bacteriuria: If future urine cultures are positive without symptoms, do not prescribe antibiotics—this increases resistance and provides no benefit. 1, 2, 4
  • Do not use fluoroquinolones as first-line UTI therapy: Reserve for resistant organisms; use nitrofurantoin, fosfomycin, or trimethoprim-sulfamethoxazole first. 1, 2, 10
  • Do not initiate metformin at eGFR 34 mL/min/1.73 m²: Risk of lactic acidosis outweighs benefit. 5
  • Do not target hemoglobin >11.5 g/dL with ESAs: Increases cardiovascular events and mortality. 1
  • Do not delay nephrology referral: Her eGFR is borderline for referral and has fluctuated significantly—early co-management improves outcomes. 3

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

2
Guideline

Management of Dysuria in Elderly Patients

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

4
Guideline

Urinary Tract Infection Diagnosis and Evaluation

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

10
Guideline

Frontline Treatment for UTI in Elderly Females

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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