Management of CKD with GFR 60-90 mL/min/1.73 m²
For patients with GFR 60-90 mL/min/1.73 m² (CKD Stage 2), management focuses on screening for kidney damage markers, treating underlying causes, controlling blood pressure to <130/80 mmHg, and implementing cardiovascular risk reduction strategies. 1
Confirm CKD Diagnosis
- Measure urinary albumin-to-creatinine ratio (UACR) immediately on a random spot urine sample, as CKD Stage 2 requires evidence of kidney damage (albuminuria, structural abnormalities, or other markers) in addition to mildly decreased GFR. 1, 2
- CKD is diagnosed only if UACR ≥30 mg/g OR other markers of kidney damage persist for ≥3 months alongside GFR 60-89 mL/min/1.73 m². 1, 3
- Without evidence of kidney damage, GFR 60-89 mL/min/1.73 m² alone does NOT constitute CKD and represents normal kidney function for age. 1, 2
Blood Pressure Management
Target blood pressure <130/80 mmHg for all CKD patients regardless of stage. 1
- For patients with UACR 30-299 mg/g (moderately increased albuminuria) AND hypertension, initiate either an ACE inhibitor or ARB. 1
- For patients with UACR ≥300 mg/g (severely increased albuminuria), ACE inhibitor or ARB therapy is strongly recommended regardless of blood pressure level. 1
- Do NOT use ACE inhibitors or ARBs for primary prevention in patients with normal blood pressure, normal UACR (<30 mg/g), and normal eGFR, as this provides no benefit. 1
- Monitor serum creatinine and potassium 7-14 days after initiating or changing doses of ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists. 1
- Continue renin-angiotensin system blockade for creatinine increases ≤30% in patients without volume depletion. 1
- Never combine ACE inhibitors with ARBs, as this increases adverse events without additional cardiovascular or kidney benefits. 1
Cardiovascular Risk Reduction
- Initiate statin therapy for cardiovascular risk reduction, as CKD patients have 5-10 times higher cardiovascular mortality risk than progression to end-stage kidney disease. 1, 4
- Achieve hemoglobin A1c ≤7% in patients with diabetes to slow CKD progression. 5
- Address modifiable risk factors including smoking cessation, weight loss if BMI >25 kg/m², dietary sodium restriction to <2 grams daily, moderate alcohol intake, and regular exercise. 6
Identify and Treat Underlying Causes
- Systematically evaluate for diabetes, hypertension, glomerulonephritis, autoimmune diseases, and nephrotoxin exposures (NSAIDs, lithium, calcineurin inhibitors, aminoglycosides). 2, 3
- Review medications and discontinue nephrotoxic agents, particularly NSAIDs. 3, 5
- For diabetic patients, optimize glucose control and consider SGLT2 inhibitors with demonstrated kidney and cardiovascular benefits if eGFR ≥20 mL/min/1.73 m². 1
Monitoring Frequency
Annual monitoring of eGFR and UACR is recommended for CKD Stage 2 with low risk (UACR <30 mg/g). 1
- Increase monitoring to 2 times per year for moderate risk (UACR 30-300 mg/g). 1
- Increase monitoring to 3-4 times per year for high risk (UACR >300 mg/g) and consider nephrology referral. 1
- Check blood pressure at every clinic visit. 7
Common Pitfalls to Avoid
- Do not diagnose CKD based solely on GFR 60-89 mL/min/1.73 m² without confirming kidney damage markers, as this GFR range may be normal for age and does not meet CKD criteria without albuminuria or other damage markers. 1, 2
- Do not discontinue ACE inhibitors or ARBs for minor creatinine increases (<30%) in the absence of volume depletion, as this removes kidney protection. 1
- Do not skip albuminuria testing, as eGFR and UACR provide independent prognostic information for cardiovascular events and CKD progression. 1, 2
- Do not use urine dipstick alone; always quantify with UACR measurement for accurate risk stratification. 1, 5
Nephrology Referral Indications
Referral to nephrology is NOT routinely required for CKD Stage 2 but should be considered for: 1