Management of GFR 60 mL/min with Elevated Albumin-to-Creatinine Ratio
For a patient with GFR 60 mL/min (Stage G3a CKD) and elevated ACR, initiate an ACE inhibitor or ARB immediately, target blood pressure <140/90 mmHg (or <130/80 mmHg if ACR ≥30 mg/g), monitor kidney function annually, and treat this as established chronic kidney disease requiring active intervention. 1, 2
Classification and Risk Assessment
Your patient has Stage G3a CKD (GFR 45-59 mL/min/1.73 m²) combined with elevated albuminuria, which together indicate established chronic kidney disease requiring treatment. 1
The specific albuminuria category depends on the ACR value:
- Category A2 (ACR 30-299 mg/g): Moderately increased albuminuria, conferring approximately 50% increased cardiovascular risk 2
- Category A3 (ACR ≥300 mg/g): Severely increased albuminuria, indicating substantially higher risk 1
This combination creates synergistic risk: The presence of both reduced GFR and albuminuria exponentially increases the risk of progression to end-stage renal disease and all-cause mortality compared to either abnormality alone. 3, 4 According to the KDIGO risk stratification grid, Stage G3a with Category A2 albuminuria places the patient in the "orange" risk zone requiring treatment and monitoring twice yearly, while G3a with A3 albuminuria requires nephrology referral. 1
Primary Treatment: RAAS Blockade
Start either an ACE inhibitor or ARB as first-line therapy—these agents have equivalent efficacy for reducing albuminuria, slowing CKD progression, and reducing cardiovascular events. 2 The choice between ACE inhibitor versus ARB is based on tolerability (ACE inhibitors cause cough in 10-15% of patients) rather than efficacy differences.
Target a ≥30% reduction in urinary albumin within 3-6 months of initiating therapy, as this magnitude of reduction predicts slower CKD progression regardless of baseline albuminuria level. 2
Critical Monitoring After RAAS Blockade Initiation
Expect serum creatinine to increase up to 30% from baseline within 2-4 weeks of starting an ACE inhibitor or ARB—this is not acute kidney injury and should not prompt discontinuation. 1 The ACCORD BP trial demonstrated that patients with up to 30% creatinine increase on RAAS blockade had no increased mortality or progressive kidney disease compared to those without creatinine rise. 1
Do not combine ACE inhibitors with ARBs—dual RAAS blockade increases risks of hyperkalemia and acute kidney injury without additional benefit for CKD progression or mortality. 5 The VA NEPHRON-D trial specifically demonstrated that combining losartan with lisinopril in diabetic patients with elevated ACR and GFR 30-90 mL/min provided no benefit but increased adverse events. 5
Blood Pressure Management
Target blood pressure <140/90 mmHg at minimum, with consideration of <130/80 mmHg specifically in patients with albuminuria (ACR ≥30 mg/g), as lower targets slow CKD progression in this subgroup. 2
If the ACE inhibitor or ARB alone does not achieve blood pressure goals, add either:
- A thiazide-like diuretic (chlorthalidone or indapamide), or
- A dihydropyridine calcium channel blocker (amlodipine or nifedipine) 2
Avoid NSAIDs in this patient population, as coadministration with RAAS blockade in patients with compromised renal function can cause acute deterioration of kidney function and attenuate the antihypertensive effect. 5
Monitoring Schedule
Annual assessment of eGFR and urine ACR is appropriate for Stage G3a CKD with moderately increased albuminuria (Category A2). 1, 2 However, if the patient has severely increased albuminuria (Category A3), increase monitoring to twice yearly. 1
Before making treatment decisions based on albuminuria, confirm with 2-3 specimens collected over 3-6 months, as single measurements can be affected by exercise, urinary tract infection, menstruation, and other transient factors. 2, 6
Increase monitoring frequency if any of the following occur:
- eGFR declines >5 mL/min/1.73 m² per year 2
- eGFR decreases ≥30% over 2 years 6
- Albuminuria increases despite treatment 2
- New medications are added that affect kidney function 2
A ≥30% decrease in eGFR over 2 years or sustained decline ≥5 mL/min/1.73 m²/year defines rapid progression and warrants nephrology referral. 6
Additional Considerations for Diabetic Patients
If the patient has diabetes, metformin is safe and appropriate at GFR 60 mL/min/1.73 m² and can be continued until eGFR falls below 30 mL/min/1.73 m². 2
Consider adding an SGLT2 inhibitor or GLP-1 receptor agonist if additional glucose control is needed beyond metformin, as these agents provide direct kidney protection independent of glucose lowering, reduce CKD progression, and lower cardiovascular risk. 2
Nephrology Referral Criteria
Do not refer to nephrology at Stage G3a unless specific complications arise:
- eGFR falls below 45 mL/min/1.73 m² (Stage G3b or worse) 1
- Severely increased albuminuria (ACR >300 mg/g) in combination with G3a 1
- Rapid progression (defined above) 2, 6
- Difficult-to-control hypertension or hyperkalemia 2
- Uncertainty about CKD etiology 2
According to the KDIGO risk grid, Stage G3a with Category A2 albuminuria requires "Treat" rather than "Refer," while G3a with Category A3 albuminuria requires nephrology referral. 1
Complications Monitoring
At GFR 60 mL/min, the primary concern is cardiovascular risk rather than metabolic complications of CKD. 7 Albuminuria independently predicts cardiovascular mortality and ESRD risk but is not strongly associated with anemia, acidosis, or hyperphosphatemia at this level of kidney function. 7 These metabolic complications become relevant at GFR <30 mL/min/1.73 m². 7
Monitor for: