What is the appropriate clinical work‑up for an adult with hypertension, hyperlipidemia and an estimated glomerular filtration rate of 69 mL/min/1.73 m² (stage 2 chronic kidney disease)?

Clinical Workup for Stage 2 CKD with Hypertension and Hyperlipidemia

For an adult with hypertension, hyperlipidemia, and a GFR of 69 mL/min/1.73 m² (Stage 2 CKD), immediately measure urine albumin-to-creatinine ratio (ACR) to determine disease severity and guide nephroprotective therapy, then initiate appropriate medications based on albuminuria status.

Immediate Laboratory Assessment Required

• Measure urine albumin-to-creatinine ratio (ACR) from a spot urine sample to stratify kidney disease risk and determine treatment intensity 1, 2

• Confirm abnormal ACR results with 2 of 3 specimens collected over 3-6 months due to biological variability 3

• ACR ≥30 mg/g indicates kidney damage requiring ACE inhibitor or ARB therapy regardless of blood pressure level 2

• ACR ≥300 mg/g strongly indicates need for renin-angiotensin system blockade and nephrology referral 2

• Check serum potassium and creatinine at baseline before initiating any new medications 3

• Assess lipid panel if not recently checked 1

• Evaluate for other cardiovascular risk factors including smoking status, diabetes screening (HbA1c), and calculate 10-year ASCVD risk 1

Blood Pressure Management

Target systolic blood pressure <130 mmHg (and <130 mmHg if tolerated, but not <120 mmHg) 1, 2

• This BP target applies to all adults with CKD and hypertension, with strong evidence from the SPRINT trial 1
• If ACR ≥30 mg/g: Start ACE inhibitor or ARB immediately as first-line therapy, even if blood pressure is normal, because these agents provide nephroprotection independent of BP lowering 1, 2
• If ACR <30 mg/g: Consider ACE inhibitor or ARB for hypertension management, though the nephroprotective indication is less strong 1

Monitoring After ACE Inhibitor/ARB Initiation

• Recheck serum creatinine and potassium within 2-4 weeks of starting or increasing dose 1
• Continue ACE inhibitor or ARB unless serum creatinine rises by more than 30% within 4 weeks 1
• A modest creatinine increase (<30%) represents expected hemodynamic changes and is not an indication to stop therapy 3, 2
• Hyperkalemia can often be managed with dietary modification or potassium binders rather than stopping the RAS inhibitor 1

Nephroprotective Medication Algorithm

If ACR ≥200 mg/g (≥20 mg/mmol):

• Start SGLT2 inhibitor (empagliflozin, canagliflozin, or dapagliflozin) immediately for patients with eGFR ≥20 mL/min/1.73 m² 1, 3
• SGLT2 inhibitors reduce CKD progression and cardiovascular events with Level 1A evidence 1
• Continue SGLT2 inhibitor even if eGFR falls below 20 during therapy, unless not tolerated or dialysis is initiated 1
• An initial reversible eGFR decline of 2-3 mL/min/1.73 m² within the first 2 weeks is expected and does not warrant discontinuation 3

If ACR 30-199 mg/g with diabetes:

• Start SGLT2 inhibitor (1A recommendation) 1
• Consider nonsteroidal mineralocorticoid receptor antagonist (finerenone) if eGFR >25 mL/min/1.73 m² with normal potassium and persistent albuminuria despite maximum tolerated RAS inhibitor dose 1

If ACR <200 mg/g without diabetes:

• Consider SGLT2 inhibitor (2B recommendation for eGFR 20-45 mL/min/1.73 m²; reasonable for eGFR 45-90 mL/min/1.73 m²) 1
• The evidence is strongest for patients with albuminuria, but benefits extend to those without significant albuminuria 1

Lipid Management

• Treat hyperlipidemia according to cardiovascular risk, as 71% of adults with hypertension and 63.2% with hypercholesterolemia have overlapping conditions 1
• Most patients with CKD have 10-year ASCVD risk ≥10%, placing them in high-risk category requiring statin therapy 1
• Statins do not require dose adjustment at this level of kidney function 1

Monitoring Schedule

Until blood pressure goal is achieved:

• Follow-up every 6-8 weeks with BP checks and medication adjustments 1

Once BP target is reached:

• Laboratory monitoring (creatinine, eGFR, ACR, potassium) and clinic follow-up every 3-6 months depending on medication regimen and clinical stability 1
• Assess eGFR and albuminuria at least annually, more frequently if at higher risk of progression 1

For Stage 2 CKD specifically:

• Monitor eGFR and ACR every 6 months given the GFR category and presence of hypertension 3, 2

Nephrology Referral Indications

Consider nephrology referral if:

• ACR ≥300 mg/g (especially with progressive increase) 2
• Rapid eGFR decline (>5 mL/min/1.73 m² per year) 1
• Decline in GFR category accompanied by ≥25% drop in eGFR from baseline 1
• Uncertainty about etiology of kidney disease 2
• Difficulty managing complications such as anemia, mineral bone disease, or metabolic acidosis 2

Critical Pitfalls to Avoid

• Do not stop ACE inhibitor/ARB for creatinine increases <30% without evidence of volume depletion, as withdrawal eliminates nephroprotection 3, 2
• Avoid NSAIDs entirely in patients with CKD taking RAS blockers, as the combination dramatically increases acute kidney injury risk 4
• The "triple whammy" of NSAIDs + ACE inhibitor/ARB + diuretic is specifically contraindicated 4
• Do not discontinue SGLT2 inhibitor for the expected initial eGFR dip of 2-3 mL/min/1.73 m² 3
• Do not rely on serum creatinine alone; always calculate eGFR using the CKD-EPI equation 2
• Normal creatinine does not exclude significant kidney dysfunction, especially in elderly patients with reduced muscle mass 2

Additional Considerations

• Screen for diabetes if not already done, as 27.2% of hypertensive patients have diabetes 1
• Address smoking cessation if applicable, as smoking is a major modifiable CVD risk factor 1
• Educate patient about "sick day rules": temporarily discontinue ACE inhibitor/ARB, diuretics, and SGLT2 inhibitor during acute illnesses with volume depletion 1, 4
• Withhold SGLT2 inhibitor during prolonged fasting, surgery, or critical illness due to ketoacidosis risk 1