From the Guidelines
The patient with a GFR of 43.1 ml/min/1.73m² and creatinine of 1.8 mg/dL should be assessed and managed as having chronic kidney disease (CKD) stage 3b, with a focus on slowing disease progression and managing related complications, as recommended by the Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guideline 1.
Key Management Recommendations
- Blood pressure control to a target of <130/80 mmHg, preferably with an ACE inhibitor or ARB if tolerated, to reduce proteinuria and slow CKD progression 1.
- Medication dosages for drugs cleared by the kidneys should be adjusted appropriately to prevent nephrotoxicity.
- A kidney-friendly diet with moderate protein restriction (0.8 g/kg/day), reduced sodium (<2.3 g/day), and potassium restriction if levels are elevated, to reduce the strain on the kidneys.
- Regular monitoring of kidney function every 3-6 months is recommended, along with screening for complications like anemia, metabolic bone disease, and acidosis, as small fluctuations in GFR are common and do not necessarily indicate progression 1.
- Nephrotoxic medications including NSAIDs and certain antibiotics should be avoided to prevent further kidney damage.
- Maintaining good glycemic control if diabetic (HbA1c target 7-8%) and addressing cardiovascular risk factors is essential as CKD significantly increases cardiovascular disease risk.
- Referral to a nephrologist is appropriate at this stage to help manage the condition and potentially slow progression to more advanced kidney disease.
Monitoring and Follow-up
- The exact frequency of GFR and albuminuria monitoring will depend on the severity of CKD and the risk for and rate of progression, with a guide to the frequency of monitoring provided by the KDIGO clinical practice guideline 1.
- An approach involving an assessment of change in eGFR category confirmed by a minimal percentage of change in eGFR (25% or greater) was recommended to define progression, to ensure that small changes in GFR are not misinterpreted to represent progression 1.
From the FDA Drug Label
5.3 Impaired Renal Function Monitor renal function periodically in patients treated with lisinopril. Changes in renal function including acute renal failure can be caused by drugs that inhibit the renin-angiotensin system. Patients whose renal function may depend in part on the activity of the renin-angiotensin system (e.g., patients with renal artery stenosis, chronic kidney disease, severe congestive heart failure, post-myocardial infarction or volume depletion) may be at particular risk of developing acute renal failure on lisinopril.
Lisinopril Use with GFR 43.1 and Cr 1.8:
- The patient's GFR is 43.1, indicating chronic kidney disease.
- The patient's creatinine level is 1.8, which is elevated.
- Lisinopril can cause changes in renal function, including acute renal failure, especially in patients with pre-existing renal impairment.
- It is recommended to monitor renal function periodically in patients treated with lisinopril.
- Consider withholding or discontinuing therapy in patients who develop a clinically significant decrease in renal function on lisinopril 2.
- Lisinopril should be used with caution in patients with renal impairment. 2
From the Research
Understanding GFR and Creatinine Levels
- A Glomerular Filtration Rate (GFR) of 43.1 and a creatinine level of 1.8 indicate impaired kidney function, as GFR is a key indicator of kidney health 3.
- The GFR value is estimated using serum biomarkers such as creatinine, which is widely employed for this purpose 3, 4.
Interpreting GFR and Creatinine Values
- A GFR of 43.1 falls into stage 3 of Chronic Kidney Disease (CKD), according to the Kidney Disease Improving Global Outcomes (KDIGO) classifications 5.
- Creatinine levels are used in conjunction with age, sex, and other factors to estimate GFR, but the resulting value is only a population average and may not accurately reflect individual kidney function 3.
Management and Treatment
- Angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB) are commonly used to manage CKD and may help slow disease progression, but their effectiveness in early stages (1-3) is less certain 5.
- The use of ACEi/ARB therapy has been shown to improve split renal function in patients with primary hypertension, particularly in those with certain differences in split renal function 6.
Assessment and Monitoring
- Regular assessment of GFR and creatinine levels is crucial for monitoring kidney function and adjusting treatment as needed 7.
- The choice of GFR estimating equation, such as the Modification of Diet in Renal Disease (MDRD) or Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations, can impact the accuracy of GFR estimates 7.