Comprehensive Management Scenario
Learning Objectives: Learners will demonstrate competency in CKD staging and progression assessment, implement evidence-based strategies for slowing CKD progression, recognize and manage CKD-related complications including anemia and mineral bone disease, and develop appropriate preparation strategies for renal replacement therapy.
Case Presentation – Outpatient Nephrology Clinic:
Mr. James Rodriguez, a 58-year-old Hispanic male with a 12-year history of type 2 diabetes mellitus and 8-year history of hypertension, presents to the nephrology clinic for initial consultation regarding chronic kidney disease. He was referred by his primary care physician after routine laboratory work revealed an estimated glomerular filtration rate of 28 mL/min/1.73m² and persistent proteinuria.
The patient’s diabetes has been managed with metformin, glipizide, and insulin glargine, though his glycemic control has been suboptimal with hemoglobin A1c values ranging from 8.5% to 9.2% over the past two years. His hypertension has been treated with lisinopril 20 mg daily and hydrochlorothiazide 25 mg daily, with blood pressure readings typically in the 140-150/85-95 mmHg range during primary care visits.
Historical Progression Review:
Review of available laboratory data over the past five years reveals a concerning pattern of progressive kidney function decline. Five years ago, his serum creatinine was 1.3 mg/dL with an eGFR of 58 mL/min/1.73m². Three years ago, creatinine had increased to 1.8 mg/dL with eGFR of 42 mL/min/1.73m². Most recent laboratory studies show creatinine of 2.4 mg/dL with eGFR of 28 mL/min/1.73m², representing a decline in kidney function of approximately 10 mL/min/1.73m² per year.
Proteinuria has been consistently present, with urine protein-to-creatinine ratios ranging from 1,200 to 1,800 mg/g over the past three years. The patient reports no history of kidney stones, urinary tract infections, or gross hematuria. Family history is significant for diabetes in both parents and end-stage renal disease requiring dialysis in his father.
Interactive Decision Point 1: CKD Staging and Risk Assessment
1) What stage of chronic kidney disease does this patient have, and what are the key features that define each CKD stage?
2) What factors in this patient’s history suggest diabetic nephropathy as the underlying cause, and what additional testing would you consider?
3) How would you assess this patient’s risk for progression to end-stage renal disease, and what interventions would you prioritize?
Comprehensive Physical Examination:
The patient appears well-developed and well-nourished but reports increased fatigue over the past six months. Vital signs reveal blood pressure of 152/88 mmHg, heart rate of 78 beats per minute, and BMI of 31.2 kg/m². Cardiovascular examination shows regular rhythm with a soft systolic murmur at the left sternal border. Fundoscopic examination reveals mild diabetic retinopathy with scattered microaneurysms and hard exudates.
Extremity examination shows trace bilateral pedal edema and diminished pedal pulses. Neurological examination reveals decreased sensation to monofilament testing in both feet, consistent with diabetic peripheral neuropathy. No evidence of uremic symptoms such as pericardial friction rub or asterixis is present.
Comprehensive Laboratory Assessment:
Current laboratory studies reveal multiple abnormalities consistent with CKD stage 4. In addition to the elevated creatinine and reduced eGFR, the patient has developed several CKD-related complications. Hemoglobin is 9.8 g/dL with mean corpuscular volume of 88 fL, suggesting anemia of chronic kidney disease. Iron studies show serum iron of 65 μg/dL, total iron-binding capacity of 280 μg/dL, transferrin saturation of 23%, and ferritin of 180 ng/mL.
Mineral and bone metabolism parameters are abnormal with serum calcium of 8.9 mg/dL, phosphorus of 4.8 mg/dL, intact parathyroid hormone of 185 pg/mL (normal 15-65 pg/mL), and 25-hydroxyvitamin D of 18 ng/mL. Lipid profile shows total cholesterol of 220 mg/dL, LDL cholesterol of 145 mg/dL, HDL cholesterol of 35 mg/dL, and triglycerides of 280 mg/dL.
Interactive Decision Point 2: Complication Management
1) What are the major complications of chronic kidney disease, and at what stages do they typically develop?
2) How would you approach the management of this patient’s anemia and mineral bone disease?
3) What are the target goals for various parameters in CKD management, and how would you prioritize interventions?
Anemia Management Strategy:
The patient’s anemia workup reveals iron deficiency with transferrin saturation below 30% and ferritin below 200 ng/mL in the setting of CKD. Initial management includes oral iron supplementation with ferrous sulfate 325 mg three times daily, along with vitamin C to enhance absorption. Patient education focuses on taking iron supplements on an empty stomach and avoiding concurrent calcium or antacid use.
Given the hemoglobin level below 10 g/dL and symptoms of fatigue, consideration is given to erythropoiesis-stimulating agent therapy. However, the decision is made to optimize iron stores first and reassess hemoglobin response over the next 4-6 weeks before initiating ESA therapy.
Mineral and Bone Disease Management:
The elevated parathyroid hormone and low vitamin D levels indicate secondary hyperparathyroidism requiring intervention. Treatment is initiated with cholecalciferol 50,000 units weekly for 8 weeks to correct vitamin D deficiency, followed by maintenance dosing of 2,000 units daily. Phosphorus restriction is implemented with dietary counseling and consideration of phosphate binders if dietary measures are insufficient.
Interactive Decision Point 3: Progression Prevention
1) What lifestyle modifications are important for slowing CKD progression?
2) How would you optimize this patient’s antihypertensive regimen for both blood pressure control and renoprotection?
3) What are the evidence-based strategies for slowing diabetic nephropathy progression, and how would you implement them in this patient?
Comprehensive Management Plan:
Blood pressure management is optimized by increasing lisinopril to 40 mg daily and adding amlodipine 5 mg daily while discontinuing hydrochlorothiazide due to reduced efficacy at this level of kidney function. Target blood pressure is set at less than 130/80 mmHg given the presence of diabetes and proteinuria.
Glycemic control optimization involves collaboration with endocrinology to adjust diabetes medications. Metformin is discontinued due to eGFR below 30 mL/min/1.73m², and insulin regimen is intensified with addition of rapid-acting insulin with meals. Target hemoglobin A1c is set at less than 7% if achievable without significant hypoglycemia risk.
Renal Replacement Therapy Preparation:
Given the patient’s eGFR of 28 mL/min/1.73m² and rate of progression, preparation for renal replacement therapy is initiated. Patient education begins regarding dialysis modalities and kidney transplantation options.
Interactive Decision Point 4: Long-term Management
1) What are the different types of renal replacement therapy, and what factors influence modality selection?
2) How would you structure follow-up care for this patient, and what parameters require regular monitoring?
3) What are the optimal timing considerations for dialysis initiation and transplant evaluation?
Case Evolution – 6-Month Follow-up:
At six-month follow-up, the patient shows mixed results from interventions. Blood pressure has improved to an average of 135/82 mmHg with the optimized antihypertensive regimen. Hemoglobin A1c has decreased to 7.8%, representing improvement but not yet at target. Hemoglobin has increased to 10.5 g/dL following iron supplementation, and vitamin D levels have normalized.
However, kidney function has continued to decline with eGFR now at 15 mL/min/1.73m², and proteinuria remains elevated at 1,600 mg/g creatinine. The patient has developed mild uremic symptoms including decreased appetite and subtle cognitive changes reported by his family.
Advanced Management Considerations:
Preparation for dialysis becomes more urgent with declining kidney function and emerging uremic symptoms. Arteriovenous fistula creation is scheduled, and intensive patient education regarding dialysis modalities is provided. Home dialysis options including peritoneal dialysis are discussed, and the patient expresses interest in this modality due to work schedule flexibility.
Expert Commentary:
This case illustrates the complex, multifaceted management required for patients with advanced CKD. The combination of diabetes and hypertension represents the most common cause of end-stage renal disease, and early intervention with ACE inhibitors, optimal glycemic control, and management of CKD complications can slow progression. The case emphasizes the importance of timely preparation for renal replacement therapy to avoid urgent dialysis initiation.