Management of Patients with Decreased eGFR

Classification and Monitoring

The American Diabetes Association recommends that all patients with diabetes should undergo initial screening for CKD at diagnosis and at least annually thereafter, including urine routine, urinary albumin/creatinine ratio (UACR), and serum creatinine for eGFR calculation 1
Monitoring frequency should increase with CKD progression; patients with eGFR <60 mL/min/1.73 m² should have more frequent monitoring of renal function, electrolytes, and medication dosing 2
Chronic kidney disease (CKD) is defined as chronic abnormalities of kidney structure and function, with stages determined by eGFR levels 1

Refer patients to nephrology services when eGFR <30 mL/min/1.73 m² (CKD stages 4-5) 3
Additional referral criteria include abrupt sustained fall in GFR or acute kidney injury 2, significant albuminuria (ACR ≥300 mg/g or ≥30 mg/mmol) 1, urinary abnormalities (red cell casts, RBC >20 per high power field) 2, refractory hypertension (requiring 4+ antihypertensive agents) 2, persistent electrolyte abnormalities 2, recurrent nephrolithiasis 2, and hereditary kidney disease 3

Metformin dosing should be adjusted based on eGFR, with temporary discontinuation at the time of or before iodinated contrast imaging procedures in patients with eGFR 30-60 mL/min/1.73 m² 4
SGLT2 inhibitors are recommended for patients with type 2 diabetes and CKD regardless of HbA1c level, and reduce renal tubular glucose reabsorption, weight, blood pressure, intraglomerular pressure, and albuminuria 5, 4
GLP-1 receptor agonists have shown renal protective effects and are preferred for patients with eGFR <20 mL/min/1.73 m², reducing the risk of new or worsening nephropathy by 22-36% 5, 4
ACE inhibitors or ARBs are preferred treatments for patients with diabetes, hypertension, and UACR >30 mg/g 1
Monitor serum potassium in patients with eGFR <60 mL/min/1.73 m² receiving ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists 6

Protein intake should be approximately 0.8 g/kg/day for patients with non-dialysis dependent CKD 1, 4
Higher protein intake (>20% of daily calories or >1.3 g/kg/day) is associated with increased albuminuria, more rapid kidney function loss, and cardiovascular mortality 4, 7
Restrict dietary sodium to <2,300 mg/day to control blood pressure and reduce cardiovascular risk 4, 2
Individualize potassium restriction based on serum potassium levels, especially in patients with reduced eGFR 4, 2

Monitor and manage complications of CKD when eGFR falls below 60 mL/min/1.73 m², including elevated blood pressure, volume overload, electrolyte abnormalities, anemia, and metabolic bone disease 2
Consider renal replacement therapy (dialysis) for patients with eGFR <30 mL/min/1.73 m² 1

Avoid nephrotoxic medications (e.g., NSAIDs) in patients with decreased eGFR 6
Adjust medication dosages based on eGFR levels 6
Do not reduce protein intake below 0.8 g/kg/day as it does not alter glycemic measures, cardiovascular risk, or the course of GFR decline 4, 7
Do not withhold immunosuppressive therapy based solely on low eGFR in cases of active glomerulonephritis with preserved renal parenchyma, significant acute tubular necrosis, and/or no significant fibrosis or atrophy 8, 9