What is the appropriate management for an 81-year-old woman with an estimated glomerular filtration rate of 26 mL/min/1.73 m² (stage 4 chronic kidney disease)?

Management of Stage 4 CKD in an 81-Year-Old Woman

An 81-year-old woman with eGFR 26 mL/min/1.73 m² has Stage 4 chronic kidney disease requiring comprehensive management focused on slowing progression, managing complications, and planning for renal replacement therapy. 1

Immediate Assessment Priorities

Confirm CKD Diagnosis and Etiology

• Verify that reduced eGFR has persisted for ≥3 months, as CKD requires chronicity 2
• Obtain urine albumin-to-creatinine ratio (UACR) to quantify proteinuria and assess cardiovascular risk 2
• Review medication list to identify and eliminate nephrotoxins, particularly NSAIDs, which must be strictly avoided at this eGFR level 2
• Investigate underlying cause: diabetes, hypertension, glomerulonephritis, or obstructive uropathy 2

Baseline Laboratory Evaluation

• Complete blood count to screen for anemia (common at this eGFR) 1
• Serum ferritin, transferrin saturation, vitamin B12, and folate 1
• Electrolytes including calcium, phosphorus, parathyroid hormone, and bicarbonate 1
• Lipid panel for cardiovascular risk stratification 1

Blood Pressure Management

Target blood pressure <130/80 mmHg using ACE inhibitor or ARB as first-line therapy if albuminuria is present. 1, 2

• The SPRINT trial demonstrated that intensive BP control (SBP <120 mmHg) in non-diabetic CKD patients with eGFR 20-60 mL/min/1.73 m² reduced cardiovascular events (HR 0.81) and all-cause mortality (HR 0.72) 1
• Monitor serum creatinine and potassium 2-4 weeks after initiating RAAS blockade 2
• Accept up to 30% acute rise in creatinine after starting ACE inhibitor/ARB, as this predicts long-term renal protection 1

Cardiovascular Risk Reduction

Aspirin Consideration

Aspirin may be considered for primary stroke prevention in this patient with Stage 4 CKD (eGFR <45 mL/min/1.73 m²), though evidence is limited. 1

• Post-hoc analysis from the HOT trial showed aspirin reduced stroke risk by 79% (HR 0.21) in patients with eGFR <45 mL/min/1.73 m² 1
• Total mortality was reduced by half (HR 0.51) and cardiovascular mortality by 64% (HR 0.36) in this subgroup 1
• However, this recommendation does not apply to Stage 5 CKD (eGFR <30 mL/min/1.73 m²), and bleeding risk must be carefully weighed 1

Statin Therapy

• Initiate statin therapy for cardiovascular protection, as traditional CV risk factor management may prevent atherosclerotic plaque even if it doesn't attenuate medial arterial calcification specific to CKD 1

Anemia Management

Screen for anemia and iron deficiency; treat with intravenous iron before considering erythropoiesis-stimulating agents (ESAs). 1

• Target hemoglobin is individualized, but avoid ESA doses that drive Hb >11-12 g/dL due to increased stroke risk 1
• Administer IV iron when ferritin <500 ng/mL and TSAT <30% 1
• If ESA is needed after optimizing iron stores, use the lowest dose to avoid transfusions while considering the patient's high vascular risk profile 1

Monitoring Disease Progression

Monitor eGFR and UACR every 3-6 months to detect rapid progression. 1, 2

• A decline of ≥5 mL/min/1.73 m² per year or ≥30% decline over 2 years indicates rapid progression requiring nephrology referral 1, 3
• A 30% decline in eGFR over 2 years carries 64% 10-year risk of ESRD (vs 18% with stable eGFR) 3
• Average annual decline in Stage 4 CKD ranges from 2.3-4.9 mL/min/1.73 m²/year in clinical trials 1

Renal Replacement Therapy Planning

Refer to nephrology immediately for renal replacement therapy education and transplant evaluation. 4

• Patients with eGFR <30 mL/min/1.73 m² should receive timely education on all treatment options: transplantation, peritoneal dialysis, hemodialysis, and conservative management 4
• Preemptive kidney transplantation (before dialysis initiation) is the preferred option when eGFR is 15-20 mL/min/1.73 m² or 2-year ESRD risk exceeds 40% 4
• At age 81, carefully assess transplant candidacy considering comorbidities, functional status, and life expectancy 1
• If transplant is not feasible, plan dialysis access (arteriovenous fistula or peritoneal dialysis catheter) when eGFR approaches 15-20 mL/min/1.73 m² 4

Medication Dosing Adjustments

Review all medications for necessary dose adjustments at eGFR 26 mL/min/1.73 m². 1, 2

• Most renally excreted drugs require dose reduction when eGFR <30 mL/min/1.73 m² 2
• Use Cockcroft-Gault equation to calculate creatinine clearance for drugs with narrow therapeutic windows, as reduced muscle mass in elderly patients may cause serum creatinine to underestimate renal insufficiency 1, 5
• Avoid metformin, NSAIDs, and other nephrotoxins entirely 2

Dietary Modifications

• Restrict dietary sodium to <2 g/day to aid blood pressure control 2
• Protein restriction (0.6-0.8 g/kg/day) may be considered at this eGFR level, though evidence for benefit is mixed 1
• Monitor and manage hyperkalemia and hyperphosphatemia through dietary restriction 1

Critical Pitfalls to Avoid

• Do not dismiss cardiovascular risk: Even Stage 4 CKD dramatically increases cardiovascular mortality, which often exceeds ESRD risk in elderly patients 1
• Do not delay nephrology referral: Patients with eGFR <30 mL/min/1.73 m² require specialist co-management 2, 4
• Do not use NSAIDs under any circumstances: They precipitate acute kidney injury and accelerate CKD progression 2
• Do not target aggressive ESA dosing: High hemoglobin targets increase stroke and cardiovascular event risk 1