What is the CKD staging and recommended management for an 80-year-old female with impaired renal function (eGFR of 65) and significant albuminuria (urine Albumin-to-Creatinine Ratio (ACR) of 419.9)?

CKD Staging and Management for 80-Year-Old Female

This patient has CKD Stage G2 A3 (moderately increased GFR with severely increased albuminuria), which represents high risk for progression and requires aggressive management with ACE inhibitor or ARB therapy, blood pressure control to ≤130/80 mmHg, and monitoring 3-4 times per year. 1

CKD Staging Classification

GFR Category

• eGFR of 65 mL/min/1.73 m² = Stage G2 (mildly decreased kidney function, range 60-89 mL/min/1.73 m²) 1

Albuminuria Category

• ACR of 419.9 mg/g = Stage A3 (severely increased albuminuria, defined as ACR >300 mg/g) 1
• This level represents macroalbuminuria and indicates significant kidney damage with high risk for cardiovascular disease, CKD progression, and mortality 1, 2

Combined Risk Assessment

• The combination of G2A3 places this patient in a high-risk category (orange zone on KDIGO risk grid) for adverse outcomes 1
• At any GFR level, ACR >300 mg/g is associated with markedly elevated risks for death, cardiovascular disease, and end-stage renal disease 1, 3

Recommended Management

Blood Pressure Control

Target BP: ≤130/80 mmHg (not ≤120/80 mmHg given age 80) 1

• Since ACR is ≥30 mg/g (actually >300 mg/g), the lower BP target of ≤130/80 mmHg applies rather than the standard ≤140/90 mmHg 1
• For patients >65 years, target systolic BP of 130-139 mmHg is appropriate, avoiding <120 mmHg 1

RAAS Blockade (Critical)

Initiate ACE inhibitor or ARB immediately 1

• With ACR >300 mg/g, ACE inhibitor or ARB therapy is a strong recommendation (Grade 1B) regardless of diabetes status 1
• These medications reduce proteinuria and slow CKD progression in both diabetic and non-diabetic nephropathy 1
• Monitor serum potassium after initiation, as hyperkalemia risk increases with these agents 1
• A transient eGFR reduction of up to 25% after starting ACE-I/ARB is expected due to hemodynamic changes and does not indicate treatment failure 1

Monitoring Frequency

Monitor eGFR and ACR 3-4 times per year 1

• The KDIGO risk grid recommends monitoring 3-4 times annually for G2A3 category 1
• More frequent monitoring (every 3 months) is warranted given the severely elevated albuminuria 1
• Check serum potassium with each monitoring visit due to ACE-I/ARB therapy 1

Additional Management Priorities

Nephrology Referral Considerations:

• Referral is strongly recommended for ACR ≥300 mg/g to coordinate care and optimize management 1, 2
• Mandatory referral if eGFR drops below 45 mL/min/1.73 m² or if there is sustained eGFR decline >5 mL/min/1.73 m² per year 1

Cardiovascular Risk Reduction:

• Statin therapy for cardiovascular risk reduction 2
• Lifestyle modifications: sodium restriction <2 g/day, smoking cessation, exercise 30 minutes 5 times weekly 1

Nephrotoxin Avoidance:

• Avoid NSAIDs, which can worsen kidney function and increase cardiovascular risk 2
• Minimize exposure to iodinated contrast 1
• Review all medications for appropriate dosing adjustments 1, 2

Diabetes Management (if applicable):

• Target HbA1c ≤7.0%, though higher targets (≤8.0%) may be appropriate given age 80 and risk of hypoglycemia 1
• Consider SGLT2 inhibitor if diabetic, as these reduce CKD progression and cardiovascular events 1

Critical Pitfalls to Avoid

• Do not delay ACE-I/ARB initiation despite age 80—the benefit for reducing proteinuria and slowing progression outweighs risks at this albuminuria level 1
• Do not interpret initial eGFR drop as treatment failure—up to 25% reduction is hemodynamic and expected 1
• Do not use combination ACE-I plus ARB—insufficient evidence for benefit and increased risk of adverse events 1
• Do not rely on serum creatinine alone—ACR provides independent prognostic information and guides treatment intensity 1, 2
• Do not assume CKD is benign in elderly—this patient's severely elevated albuminuria confers high risk regardless of age 1, 3