How to manage a patient with CKD (Chronic Kidney Disease) stage 2, possibly with hypertension or diabetes?

Management of CKD Stage 2

For a patient with CKD stage 2 (eGFR 60-89 mL/min/1.73 m²), management centers on screening for albuminuria and implementing targeted therapies based on whether diabetes and/or hypertension are present, with SGLT2 inhibitors and RAS blockade forming the cornerstone of treatment when indicated. 1

Initial Assessment and Screening

• Measure urine albumin-to-creatinine ratio (UACR) at least annually to stratify risk and guide treatment decisions 2
• For diabetic patients, screen annually for type 1 diabetes with duration ≥5 years, and at diagnosis for all type 2 diabetes patients 2
• Measure serum creatinine at least annually to calculate eGFR and stage CKD 2
• Two of three UACR specimens collected within 3-6 months should be abnormal before confirming albuminuria status (normal <30 mg/g, microalbuminuria 30-299 mg/g, macroalbuminuria ≥300 mg/g) 2

Pharmacological Management Algorithm

If Patient Has Diabetes:

First-line therapy:

• Start SGLT2 inhibitor immediately for all patients with type 2 diabetes and CKD stage 2, regardless of albuminuria status 1, 2
• SGLT2 inhibitors reduce CKD progression and cardiovascular events independent of glucose-lowering effects 2
• Continue metformin for glycemic control at this eGFR level 2

Second-line therapy:

• Add ACE inhibitor or ARB if albuminuria (UACR ≥30 mg/g) and hypertension are present 2
• Titrate to the highest approved dose tolerated 2, 3
• For type 1 diabetes with any degree of albuminuria and hypertension, ACE inhibitors delay nephropathy progression 2
• For type 2 diabetes with microalbuminuria and hypertension, both ACE inhibitors and ARBs delay progression to macroalbuminuria 2

Third-line therapy:

• Consider nonsteroidal mineralocorticoid receptor antagonist (finerenone) if albuminuria >30 mg/g persists despite maximum tolerated RAS inhibitor 1, 2
• This requires eGFR >25 mL/min/1.73 m² and normal potassium levels 1

Additional glycemic management:

• Add GLP-1 receptor agonist with proven cardiovascular benefits if glycemic targets not met despite metformin and SGLT2 inhibitor 1, 2

If Patient Has Hypertension Without Diabetes:

First-line therapy:

• Start ACE inhibitor or ARB if albuminuria is present (UACR ≥30 mg/g) 2, 3
• Strong recommendation for severely increased albuminuria (≥300 mg/g) 1, 3
• Conditional recommendation for moderately increased albuminuria (30-299 mg/g) 1, 3
• Titrate to maximum approved dose tolerated 3

If no albuminuria:

• RAS inhibitors have not proven kidney protective benefits in this scenario 2
• Use other antihypertensive agents (calcium channel blockers, thiazide-like diuretics) to achieve blood pressure targets 3

If Patient Has Neither Diabetes Nor Hypertension:

• Consider ACE inhibitor or ARB only if albuminuria is present, even with normal blood pressure 2
• Monitor closely for development of diabetes or hypertension with annual screening 2

Blood Pressure Management

• Target systolic blood pressure <120 mmHg when tolerated using standardized office measurements 1, 3
• For patients with frailty, high fall risk, limited life expectancy, or symptomatic postural hypotension, consider less intensive targets (120-130 mmHg) 1
• Alternative target <130/80 mmHg is acceptable to reduce cardiovascular mortality and slow CKD progression 2

Monitoring Parameters for RAS Inhibitors

• Check serum creatinine and potassium within 2-4 weeks of initiating or increasing dose of ACE inhibitor or ARB 2, 3
• Continue RAS inhibitor unless creatinine rises >30% within 4 weeks of initiation or dose increase 2
• If hyperkalemia develops, implement potassium-lowering measures (moderate dietary potassium, add diuretics, sodium bicarbonate if acidotic, or GI cation exchangers) rather than immediately stopping the RAS inhibitor 2

Critical Contraindications and Pitfalls

• Never combine ACE inhibitor + ARB + direct renin inhibitor - this triple combination increases adverse events without benefit 2, 1, 3
• Avoid dual RAS inhibition (ACE inhibitor + ARB) due to increased hyperkalemia, hypotension, and acute kidney injury risk 2, 3
• Continue RAS inhibitors even when eGFR falls below 30 mL/min/1.73 m² unless specific adverse effects occur (symptomatic hypotension, uncontrolled hyperkalemia despite interventions, or acute kidney injury) 1, 3
• Do not discontinue SGLT2 inhibitors due to reversible eGFR decrease upon initiation - this is an expected hemodynamic effect, not an indication to stop therapy 1
• Advise contraception in women receiving RAS inhibitors and discontinue if pregnancy is planned or occurs 2

Lifestyle and Dietary Modifications

• Maintain protein intake at 0.8 g/kg/day - avoid high protein intake >1.3 g/kg/day as it increases progression risk 1
• Limit sodium intake to <2 g/day (<5 g sodium chloride/day) 1
• Recommend moderate-intensity physical activity for ≥150 minutes per week and avoid sedentary behavior 1
• Advise tobacco cessation for all patients who use tobacco products 2

Lipid Management

• Start statin or statin/ezetimibe combination for patients ≥50 years with eGFR <60 mL/min/1.73 m² 1
• For patients ≥50 years with eGFR ≥60 mL/min/1.73 m² (CKD stage 2), statin treatment is recommended 1

Glycemic Control Targets

• Optimize glucose control to A1C targets to reduce risk or slow progression of nephropathy 2
• In CKD stage 2, standard A1C targets apply as there is adequate time for intensive glucose control benefits to manifest (lag time of 2+ years in type 2 diabetes) 2
• Target A1C levels may be less intensive in patients with substantial comorbidity, but this is less relevant in CKD stage 2 2

Additional Monitoring

• Annual dilated eye examination for diabetic patients to screen for retinopathy 2
• Monitor for CKD complications including hyperkalemia, metabolic acidosis, hyperphosphatemia, vitamin D deficiency, secondary hyperparathyroidism, and anemia as CKD progresses 4