What changes when you progress from chronic kidney disease stage 3B to stage 4?

The stages of chronic kidney disease (CKD) are defined by ranges of eGFR, a calculated number based on serum (blood) creatinine test results. Of course, the progression of CKD is continuous, but certain healthcare protocols are set based on the discrete stages of CKD, particularly at stage 4 when eGFR drops below 30.  In this post, I’ll describe three protocols that affected me personally.

• COVID-19 antivirals.  Back when I was at stage 3B, I got COVID-19 and got a dosage adjustment for Paxlovid for “moderate renal impairment.”  I experienced only very mild symptoms with Paxlovid and did not experience a “Paxlovid rebound.”

  

  Source: Pfizer

  Once, I crossed into Stage 4 CKD, I could no longer be prescribed Paxlovid.  My option instead was Lagevrio (molnupiravir).  Lagevrio was recommended by my nephrologist because it has been shown to be safe and effective for patients with advanced chronic kidney impairment.  Personally, I started testing negative 5 days after starting Lagevrio treatment.

• Cortisone shots instead of NSAIDs for gout attacks.  When I got my first gout attack, I was prescribed Indomethacin (an NSAID) for my gout pain.  It worked fine, and I did get some immediate relief with the strict warning not to take higher doses or partake in long-term use given my CKD.  Once I crossed into stage 4, I was advised to completely avoid Indomethacin. For my last gout flare-up, I was given a cortisone shot, and it provided immediate relief.  (Note that I was warned as a diabetic that my blood sugar would temporarily go up as the result of the cortisone shot!)

Later, I was prescribed allopurinol to reduce the risk of future gout flare-ups.  I have not yet had another flare-up since getting on this drug.

• No more metformin.  As my CKD has progressed, my doctors have been weaning me off Metformin (from 2000 mg to 1000 mg to 500 mg to nothing) while increasing the Ozempic.  Right now, with stage 4 CKD, I am completely off metformin, consistent with recommendations (see below). My A1C is stable, with the Ozempic and Jardiance keeping my A1C under control.

  

  Source: PubMed

By no means is this list complete.  They are just the immediate impacts that affected me once the stage designation officially changed for me.

Are there others that you have experienced?