Management of Moderate Renal Disease (eGFR 35)

Introduction to Management

The American Diabetes Association recommends targeting blood pressure <140/90 mmHg, with consideration of <130 mmHg if tolerated, for patients with eGFR 35 mL/min/1.73 m² 1, 2
The National Kidney Foundation suggests initiating or maximizing ACE inhibitor or ARB therapy as first-line agents for blood pressure control and proteinuria reduction, even at this level of kidney function 1, 2

The American Heart Association recommends accepting up to 30% increase in serum creatinine after starting RAS blockade without discontinuing therapy, as this represents hemodynamic changes rather than kidney injury 1
The European Renal Association recommends dietary sodium restriction to <2.0 g/day (<90 mmol/day) to enhance blood pressure control and reduce proteinuria 3, 2
The International Society of Nephrology suggests considering adding mineralocorticoid receptor antagonists for refractory proteinuria, with careful potassium monitoring 2

The American College of Physicians recommends measuring urinary albumin-to-creatinine ratio (UACR) at baseline and monitoring every 3-12 months to assess disease progression and treatment response 1, 4
The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines state that a sustained reduction of >30% in proteinuria over 2 years is associated with improved renal and cardiovascular outcomes 1
The National Institute of Diabetes and Digestive and Kidney Diseases recommends more frequent monitoring (twice yearly) at this eGFR level, particularly when on RAS blockade 4

The American College of Cardiology recommends initiating statin therapy for cardiovascular risk reduction, as reduced eGFR <60 mL/min/1.73 m² is independently associated with elevated atherosclerotic cardiovascular disease risk 5, 2
The European Society of Cardiology suggests assessing ASCVD risk based on LDL-C, apolipoprotein B, triglycerides, and lipoprotein(a) levels 5
The American Heart Association recommends aligning statin dosage intensity to ASCVD risk 5

The American Diabetes Association recommends targeting HbA1c <7.0% for most patients, with individualization based on hypoglycemia risk and comorbidities 1, 4
The European Association for the Study of Diabetes suggests considering SGLT2 inhibitors to reduce CKD progression and cardiovascular events in patients with diabetes and CKD 6

The Academy of Nutrition and Dietetics recommends protein restriction to 0.8 g/kg/day for patients with eGFR <60 mL/min/1.73 m² 3
The National Kidney Foundation suggests avoiding protein intake <0.6 g/kg/day due to malnutrition risk 3
The American Heart Association recommends emphasizing plant-based protein sources 3, 2

The American Society of Nephrology recommends screening for and managing anemia with hemoglobin monitoring and consideration of iron supplementation or erythropoiesis-stimulating agents 7
The National Kidney Foundation suggests evaluating and treating mineral bone disease with monitoring of calcium, phosphorus, parathyroid hormone, and vitamin D levels 7
The European Renal Association recommends assessing for metabolic acidosis and considering bicarbonate supplementation if serum bicarbonate <22 mEq/L 7

The American College of Clinical Pharmacy recommends reviewing all medications for appropriate dosing at eGFR 35 mL/min/1.73 m² 7
The National Institute of Diabetes and Digestive and Kidney Diseases suggests avoiding nephrotoxic agents, particularly NSAIDs and aminoglycosides 7

The Infectious Diseases Society of America recommends screening for tuberculosis, hepatitis B, hepatitis C, HIV, and syphilis in clinically appropriate patients before considering any immunosuppression 8
The American Society of Nephrology suggests considering prophylactic trimethoprim-sulfamethoxazole if high-dose immunosuppression is required 8

The National Kidney Foundation recommends immediate nephrology referral at eGFR <45 mL/min/1.73 m² for coordinated care 4
The American Society of Nephrology suggests beginning education about renal replacement therapy options (hemodialysis, peritoneal dialysis, transplantation) 7

The American College of Physicians recommends eGFR and UACR every 3-6 months at this stage 4
The National Kidney Foundation suggests serum potassium monitoring with each eGFR check, especially on RAS blockade 1
The American Heart Association recommends lipid panel every 3-12 months after statin initiation 5
The European Renal Association suggests hemoglobin, calcium, phosphorus, and PTH monitoring every 6-12 months 7

The American College of Cardiology recommends not discontinuing ACE inhibitors or ARBs for creatinine increases <30% from baseline in the absence of volume depletion or hyperkalemia 1
The National Institute of Diabetes and Digestive and Kidney Diseases suggests not using maximally tolerated doses of RAS blockade rather than subtherapeutic doses, as clinical trials demonstrating efficacy used maximal dosing 1
The American Society of Nephrology recommends not delaying nephrology referral, as earlier involvement improves outcomes and preparation for renal replacement therapy 4

The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines state that proteinuria reduction is a validated surrogate endpoint for slowing CKD progression 8, 3