What are the next steps for a patient with Chronic Kidney Disease (CKD) stage 2?

Management of CKD Stage 2

For a patient with CKD Stage 2 (eGFR 60-89 mL/min/1.73 m²), the primary focus should be on estimating disease progression, implementing cardiovascular risk reduction strategies, and initiating targeted therapies based on albuminuria status and comorbidities. 1, 2

Initial Assessment and Monitoring

Establish baseline kidney function and albuminuria status:

• Measure urine albumin-to-creatinine ratio (UACR) immediately if not already done 3
• Confirm microalbuminuria (30-300 mg/g) or macroalbuminuria (>300 mg/g) with two of three specimens collected over 3-6 months 2
• Monitor eGFR and UACR at least annually going forward 3
• Assess blood pressure at every clinical contact 3

Screen for CKD complications and comorbidities:

• Evaluate for cardiovascular disease risk using the ACC/AHA Pooled Cohort Equations 3
• Check serum potassium, bicarbonate, phosphate, and vitamin D levels 3
• Screen for anemia and secondary hyperparathyroidism 4

Blood Pressure Management

Target blood pressure aggressively, as patients with CKD are automatically in the high cardiovascular risk category:

• Initiate antihypertensive therapy if BP ≥130/80 mmHg 3
• Use combination therapy with two agents of different classes if BP ≥140/90 mmHg 3
• Reassess BP within 1 month after initiating or adjusting therapy 3

Select renin-angiotensin system inhibitors (RASi) as first-line agents when albuminuria is present:

• Start ACE inhibitor or ARB for patients with UACR 30-300 mg/g (moderately increased albuminuria) 3, 2
• Start ACE inhibitor or ARB for patients with UACR ≥300 mg/g (severely increased albuminuria) 3
• Use the highest approved tolerated dose to achieve maximum benefit 3
• Check serum creatinine and potassium 2-4 weeks after initiation or dose increase 3
• Continue therapy unless creatinine rises >30% within 4 weeks or uncontrolled hyperkalemia develops 3

SGLT2 Inhibitor Therapy

Initiate an SGLT2 inhibitor for cardiorenal protection, regardless of diabetes status:

• Start SGLT2 inhibitor if UACR ≥200 mg/g (≥20 mg/mmol), as this provides proven kidney and cardiovascular benefits 3
• Consider SGLT2 inhibitor even with UACR <200 mg/g if patient has heart failure or is at high cardiovascular risk 3
• Continue SGLT2 inhibitor even if eGFR subsequently declines below 20 mL/min/1.73 m² unless not tolerated 3
• The reversible eGFR dip after initiation is expected and not an indication to discontinue 3
• Withhold during prolonged fasting, surgery, or critical illness due to ketosis risk 3

Additional Pharmacologic Interventions

For patients with type 2 diabetes:

• Add GLP-1 receptor agonist if glycemic targets not met despite metformin and SGLT2 inhibitor, prioritizing agents with cardiovascular benefits (e.g., liraglutide, semaglutide) 3
• Consider nonsteroidal mineralocorticoid receptor antagonist (finerenone) if albuminuria persists despite RASi and SGLT2 inhibitor therapy 3
• Monitor potassium closely when adding finerenone: initiate only if K+ ≤4.8 mmol/L, hold if K+ >5.5 mmol/L 3

Cardiovascular risk reduction:

• Initiate statin therapy for all patients with CKD Stage 2, as they are at elevated cardiovascular risk 4, 5
• Optimize glycemic control if diabetic (HbA1c target individualized but generally <7%) 3

Lifestyle Modifications

Implement comprehensive lifestyle interventions:

• Restrict dietary protein to 0.8 g/kg/day (the recommended daily allowance); avoid intake >1.3 g/kg/day 3
• Counsel on smoking cessation 3
• Encourage regular physical activity and weight management 3
• Provide dietary sodium restriction to support blood pressure control 5

Nephrotoxin Avoidance

Eliminate or minimize exposure to kidney-damaging agents:

• Avoid NSAIDs, which accelerate CKD progression 4, 5
• Review all medications and adjust dosing for renal function as needed 4
• Avoid aminoglycosides, tetracyclines, and other nephrotoxic antibiotics 3

Follow-Up Strategy

Establish a structured monitoring plan:

• Reassess eGFR and UACR every 6-12 months for Stage 2 CKD 3
• Monitor blood pressure every 3-6 months or more frequently if adjusting therapy 3, 2
• Check electrolytes, particularly potassium, every 6-12 months or more frequently if on RASi or MRA 3
• Educate patient about CKD, as most patients with early CKD are unaware of their diagnosis 4

Common pitfalls to avoid:

• Do not discontinue RASi for modest creatinine increases (<30% within 4 weeks), as this is hemodynamically mediated and expected 3
• Do not withhold SGLT2 inhibitors due to initial eGFR dip, which is reversible and does not indicate harm 3
• Do not delay statin therapy—cardiovascular disease is the leading cause of death in CKD patients 4
• Do not restrict dietary protein below 0.8 g/kg/day, as this provides no additional benefit 3