Management of GFR Below 15 mL/min/1.73 m²

Introduction to Management

A patient with GFR below 15 mL/min/1.73 m² requires immediate nephrology referral if not already established, intensive preparation for renal replacement therapy (RRT), and careful monitoring for clinical indications to initiate dialysis—but dialysis should NOT be started based on GFR alone 1, 2

The American Society of Nephrology recommends checking creatinine, eGFR, and potassium at least monthly, increasing to weekly or more frequently if rapid progression or clinical instability occurs 3, 4
The American Society of Nephrology suggests monitoring blood pressure at every clinic visit (minimum every 3 months) 3
The American Society of Nephrology advises monitoring nutritional status (body weight and serum albumin) every 3 months 3

The American Society of Nephrology indicates that dialysis should be initiated based on clinical symptoms, such as pericarditis, encephalopathy, intractable nausea/vomiting, bleeding diathesis, NOT GFR alone 1, 5, 2
The American Society of Nephrology recommends initiating dialysis in cases of volume overload refractory to diuretic therapy, uncontrolled hypertension despite maximal medical management, hyperkalemia unresponsive to medical therapy, and severe metabolic acidosis 5, 2

The American Society of Nephrology suggests targeting systolic BP <130 mmHg and diastolic BP <80 mmHg, and using ACE inhibitor or ARB as first-line agent 6, 3, 4
The American Society of Nephrology recommends monitoring GFR and potassium within 1 week of starting or dose escalation of ACE inhibitors or ARBs, and not routinely discontinuing them at GFR <30 as they remain nephroprotective 7
The American Journal of Kidney Diseases advises reducing dose of opioids, beta-blockers, and metformin, and avoiding NSAIDs in patients with GFR <15 mL/min/1.73 m² 7

The American Society of Nephrology recommends providing structured education regarding preparation for RRT, discussing modality options, and encouraging maintenance of employment 1, 8, 6, 4
The American Society of Nephrology suggests preserving veins suitable for vascular access, and referring for surgery to attempt construction of primary AV fistula if hemodialysis is planned 1, 8, 6

The American Society of Nephrology warns against initiating dialysis based on GFR alone, using aggressive first dialysis sessions, and causing hemodialysis-related hypotension 1, 5, 2
The American Journal of Kidney Diseases advises against routinely discontinuing ACE-I/ARB at this GFR level as they remain nephroprotective 7

Symptomatic hyperuricemia (gout) should be treated with urate‑lowering therapy in patients with advanced chronic kidney disease (eGFR < 10 mL/min/1.73 m²). 9
Initiation of urate‑lowering therapy is recommended after the first gout episode, especially when serum uric acid exceeds 9 mg/dL (≈535 µmol/L). 9

For acute gout attacks in patients with eGFR < 10 mL/min/1.73 m², low‑dose colchicine or intra‑articular/oral glucocorticoids are preferred over NSAIDs. 9