What are the management strategies for Chronic Kidney Disease (CKD) stage II?

Management of CKD Stage II

For patients with CKD Stage II (GFR 60-89 mL/min/1.73 m²), management should focus on comprehensive cardiovascular risk reduction, blood pressure control, and monitoring for disease progression, with treatment intensity determined primarily by the presence and degree of albuminuria rather than GFR alone. 1

Risk Stratification by Albuminuria

The management approach differs substantially based on albuminuria status:

• Normal albuminuria (<30 mg/g): Annual screening is sufficient; this represents low risk for progression 1
• Moderately increased albuminuria (30-299 mg/g): Requires treatment and monitoring 1-2 times yearly 1
• Severely increased albuminuria (≥300 mg/g): High-risk category requiring treatment and monitoring 3-4 times per year 1, 2

Blood Pressure Management

Target blood pressure should be ≤130/80 mmHg for all CKD Stage II patients with albuminuria ≥30 mg/g. 1, 3

RAS Blockade Strategy

• For patients with hypertension AND albuminuria: Initiate ACE inhibitor or ARB immediately and titrate to the maximum tolerated dose 1
• For patients with albuminuria ≥300 mg/g: ACE inhibitor or ARB is strongly recommended regardless of blood pressure status (Grade 1B recommendation) 2
• For patients with normal blood pressure and normal albuminuria (<30 mg/g): ACE inhibitor or ARB is NOT recommended for primary prevention 1

Monitoring After RAS Blockade Initiation

Check serum creatinine and potassium within 2-4 weeks of starting or increasing ACE inhibitor/ARB dose 1. Continue therapy unless creatinine rises >30% within 4 weeks 1. Do not discontinue for mild-to-moderate creatinine increases in the absence of volume depletion 1.

Diabetes Management (if applicable)

For patients with type 2 diabetes and CKD Stage II:

• SGLT2 inhibitors are recommended for cardiovascular and renal protection when eGFR ≥20 mL/min/1.73 m² and albuminuria is present 1, 4
• Metformin can be continued safely at this GFR level 4
• Target HbA1c ≤7.0% in most patients, though individualization is appropriate for elderly or high-risk patients 2

Cardiovascular Risk Reduction

Lipid Management

All patients ≥50 years with CKD Stage II should receive statin therapy (Grade 1B recommendation) 1. For patients 18-49 years, initiate statin if they have:

• Known coronary disease 1
• Diabetes mellitus 1
• Prior ischemic stroke 1
• 10-year cardiovascular risk >10% 1

Antiplatelet Therapy

• Aspirin is recommended for secondary prevention in patients with established cardiovascular disease 1
• For primary prevention, aspirin may be considered in high-risk individuals, but balance against bleeding risk 1

Lifestyle Modifications

Implement the following evidence-based interventions:

• Dietary protein: Target 0.8 g/kg body weight per day 1, 4
• Sodium restriction: <2,300 mg/day (ideally <2,000 mg/day) 4
• Physical activity: 150 minutes weekly of moderate-intensity exercise 4
• Mediterranean-style diet: Emphasize plant-based foods, whole grains, and limit red/processed meats 1, 4
• Smoking cessation: Essential for all patients 1

Nephrotoxin Avoidance

• Discontinue NSAIDs immediately 4
• Minimize iodinated contrast exposure 2
• Review all medications for appropriate dosing 2
• Avoid herbal supplements with potential nephrotoxicity 4

Monitoring Frequency

The frequency of monitoring depends on albuminuria category:

• Normal albuminuria: Annual eGFR and urine albumin testing 1
• Moderately increased albuminuria (30-299 mg/g): Every 6-12 months 1
• Severely increased albuminuria (≥300 mg/g): Every 3-4 months 1, 2

At each visit, assess: eGFR, urine albumin-to-creatinine ratio, serum potassium, and blood pressure 4.

Nephrology Referral Indications

Refer to nephrology if:

• Albuminuria ≥300 mg/g 2
• Uncertainty about CKD etiology 1
• Rapid decline in eGFR (>5 mL/min/1.73 m² per year) 5
• Difficulty achieving blood pressure or metabolic targets 5

Common Pitfalls to Avoid

Do not withhold ACE inhibitors/ARBs for mild creatinine elevations (<30% increase) as this represents appropriate hemodynamic response rather than kidney injury 1. The cardiovascular and renal protective benefits outweigh concerns about modest GFR reductions 1.

Do not use ACE inhibitors and ARBs in combination as dual RAS blockade increases adverse events without additional benefit 1.

Ensure contraception counseling for women of childbearing age on ACE inhibitors or ARBs, and discontinue these medications if pregnancy is planned or occurs 1.