What is the recommended management for a patient with stage G2 chronic kidney disease (estimated glomerular filtration rate 60–89 mL/min/1.73 m²)?

Management of CKD Stage G2 (eGFR 60–89 mL/min/1.73 m²)

CKD Stage G2 requires confirmation of kidney damage through albuminuria testing before diagnosis, followed by aggressive cardiovascular risk reduction and treatment of underlying causes, with the primary goal of preventing progression to advanced kidney disease. 1

Confirm the Diagnosis

• Measure urinary albumin-to-creatinine ratio (UACR) immediately on a random spot urine sample, as Stage G2 CKD requires evidence of kidney damage (UACR ≥30 mg/g) in addition to mildly decreased GFR (60–89 mL/min/1.73 m²) to meet diagnostic criteria. 2

• Verify chronicity by reviewing historical eGFR and creatinine values to confirm kidney dysfunction has persisted for at least 3 months, distinguishing CKD from acute kidney injury. 2

• If duration is unclear or less than 3 months, repeat serum creatinine and eGFR within 2–4 weeks to establish persistence. 2

• CKD Stage G2 is diagnosed only when both criteria are met: eGFR 60–89 mL/min/1.73 m² AND evidence of kidney damage (UACR ≥30 mg/g, hematuria, structural abnormalities on imaging, or biopsy-proven kidney disease) persisting ≥3 months. 1

Identify and Treat Underlying Causes

• Screen for diabetes immediately using hemoglobin A1c (≥6.5%), fasting plasma glucose (≥126 mg/dL), or 2-hour oral glucose tolerance test (≥200 mg/dL), as diabetes accounts for 30–40% of CKD cases and may be present at diagnosis in type 2 diabetes. 1, 2

• Assess for hypertension, which is present in approximately 70% of patients with elevated creatinine and represents the second leading cause of CKD in developed countries. 2

• Obtain detailed medication history focusing on nephrotoxic exposures including NSAIDs, lithium, calcineurin inhibitors, and aminoglycosides. 2

• Evaluate for glomerulonephritis by examining urinalysis for hematuria, pyuria, or casts; if present, consider autoimmune workup including complement levels (C3, C4), ANA, ANCA, and anti-GBM antibodies. 2

• Assess family history of kidney disease, as genetic disorders such as Alport syndrome, thin basement membrane disease, or APOL1-related nephropathy significantly increase CKD risk. 2

Blood Pressure Management

• Target blood pressure <130/80 mmHg for all CKD patients regardless of stage, using standardized measurement techniques. 2, 3

• Initiate an ACE inhibitor or ARB as first-line therapy in patients with UACR 30–299 mg/g (moderately increased albuminuria) AND hypertension. 2

• Strongly recommend ACE inhibitor or ARB therapy for patients with UACR ≥300 mg/g (severely increased albuminuria) regardless of blood pressure level, as these agents provide renoprotection beyond blood pressure control. 2

• Monitor serum creatinine and potassium within 5–7 days after initiating or adjusting ACE inhibitor/ARB doses. 2, 3

• Continue ACE inhibitor/ARB therapy if creatinine rises <30% from baseline, as this reflects expected hemodynamic effects rather than kidney injury. 2, 3

• Discontinue or reduce dose only if creatinine rises >30% from baseline or potassium exceeds 5.5 mEq/L. 2, 3

Diabetes Management (if present)

• Optimize glucose control targeting hemoglobin A1c <7% in most patients, adjusting based on individual risk-benefit assessment. 2

• Consider SGLT2 inhibitors with demonstrated kidney and cardiovascular benefits if eGFR ≥20 mL/min/1.73 m², as these agents reduce CKD progression and cardiovascular events in patients with diabetes and CKD. 2, 3

Cardiovascular Risk Reduction

• Initiate statin therapy for cardiovascular risk reduction, as CKD patients have 5–10 times higher cardiovascular mortality risk than risk of progression to end-stage kidney disease. 2

• Recognize that cardiovascular disease is the leading cause of death in CKD patients, not kidney failure itself, making aggressive cardiovascular risk modification the priority. 2

Monitoring Schedule

• Monitor eGFR and UACR annually for low-risk patients (UACR <30 mg/g). 2

• Increase monitoring to twice yearly for moderate-risk patients (UACR 30–300 mg/g). 2

• Monitor 3–4 times per year for high-risk patients (UACR >300 mg/g) and consider nephrology referral. 2

Nephrology Referral Indications

• Consider nephrology referral for continuously increasing albuminuria despite optimal management, difficulty managing CKD complications, or resistant hypertension. 2

• Refer immediately if there is uncertainty about etiology, atypical features suggesting non-diabetic kidney disease (e.g., absence of diabetic retinopathy in diabetic patients, rapid eGFR decline, active urinary sediment), or consideration of kidney biopsy. 2

Critical Pitfalls to Avoid

• Never diagnose CKD Stage G2 based on eGFR alone—you must document evidence of kidney damage (albuminuria, hematuria, or structural abnormalities) persisting ≥3 months. 1, 2

• Do not skip albuminuria testing, as eGFR and UACR provide independent prognostic information for cardiovascular events, CKD progression, and mortality. 2

• Avoid discontinuing ACE inhibitors/ARBs prematurely for creatinine rises <30%, as initial increases are expected hemodynamic effects and do not indicate harm. 2, 3

• Do not rely on serum creatinine alone—always calculate eGFR using validated equations (CKD-EPI 2021) that account for age, sex, and race. 2, 4

• Avoid NSAIDs entirely, as they worsen renal function, increase cardiovascular risk, and accelerate CKD progression. 2