How to manage stage 2 Chronic Kidney Disease (CKD) in an adult patient with impaired renal function, potential hypertension, and diabetes?

Management of Stage 2 CKD with eGFR 64 and Creatinine 1.04

Start an SGLT2 inhibitor immediately if you have diabetes or albuminuria ≥200 mg/g, as this is the single most impactful intervention to slow CKD progression and reduce cardiovascular mortality based on the strongest current evidence. 1

Blood Pressure Management

Target Blood Pressure

• If albuminuria <30 mg/24h: Target BP ≤140/90 mmHg 1
• If albuminuria ≥30 mg/24h: Target BP ≤130/80 mmHg 1
• Check for albuminuria first, as this determines your BP target and medication strategy 1

First-Line Antihypertensive Therapy

• Start ACE inhibitor or ARB (not both) if you have any albuminuria (≥30 mg/24h), regardless of diabetes status 1
• Use maximum tolerated dose—the proven benefits in trials were achieved at these doses 1
• If albuminuria <30 mg/24h: ACE inhibitor or ARB can still be used for hypertension control, but other antihypertensive classes are equally acceptable 1

Monitoring After Starting ACE Inhibitor/ARB

• Check creatinine, eGFR, and potassium within 2-4 weeks of initiation 1
• Continue therapy unless creatinine rises >30% within 4 weeks—smaller increases are expected and acceptable 1
• Do not stop for hyperkalemia unless it remains uncontrolled despite potassium-lowering measures 1
• Continue ACE inhibitor/ARB even when eGFR falls below 30 mL/min/1.73 m² 1

SGLT2 Inhibitor Therapy

Indications (Choose One)

1. Type 2 diabetes with eGFR ≥20: Start SGLT2 inhibitor (1A recommendation) 1
2. Albuminuria ≥200 mg/g with eGFR ≥20: Start SGLT2 inhibitor regardless of diabetes status (1A recommendation) 1
3. Heart failure: Start SGLT2 inhibitor regardless of albuminuria level (1A recommendation) 1
4. eGFR 20-45 with albuminuria <200 mg/g: Consider SGLT2 inhibitor (2B recommendation) 1

Key Points

• SGLT2 inhibitors reduce progression to kidney failure by 39-40% 2
• Continue even if eGFR drops below 20 unless not tolerated 1
• Expect a reversible eGFR decrease initially—this is not a reason to stop 1
• Withhold during prolonged fasting, surgery, or critical illness due to ketosis risk 1

Additional Medications for Diabetes

If Diabetes Present

• Ensure ACE inhibitor/ARB is at maximum tolerated dose first 2
• Add SGLT2 inhibitor as described above 1, 2
• Consider GLP-1 receptor agonist (liraglutide or semaglutide) if additional glycemic control needed or cardiovascular risk remains high 2
• If albuminuria persists despite ACE inhibitor/ARB + SGLT2 inhibitor: Consider nonsteroidal mineralocorticoid receptor antagonist (finerenone) if eGFR >25 and potassium normal 1

Cardiovascular Risk Reduction

• Start statin therapy for all patients ≥50 years with eGFR <60 3
• Target LDL-C <55 mg/dL if very high cardiovascular risk; add ezetimibe if needed 2
• Monitor for volume depletion if on diuretics, especially after starting SGLT2 inhibitor 2

Lifestyle Modifications

• Sodium restriction to <1500 mg/day 3
• Aerobic exercise 90-150 minutes/week 3
• Weight loss if overweight/obese 3
• Smoking cessation 3
• These interventions directly slow CKD progression independent of medications 3

Monitoring Schedule

• Check creatinine, eGFR, electrolytes, and urine albumin-to-creatinine ratio 3 times per year for Stage 2 CKD 3
• More frequent monitoring (2-4 weeks) after medication changes 1

Common Pitfalls to Avoid

• Do not combine ACE inhibitor with ARB—evidence shows harm with combination therapy 1
• Do not stop ACE inhibitor/ARB for creatinine increases <30%—this is expected and beneficial long-term 1
• Do not withhold SGLT2 inhibitor due to initial eGFR dip—this is reversible and does not indicate harm 1
• Do not reduce ACE inhibitor/ARB dose prematurely for hyperkalemia—use potassium-lowering strategies first 1