• Cause
• GFR category, based on eGFR
• Albuminuria category, based on urine ACR

GFR grades (often called CKD stages)

Albuminuria grades

• C: cause
• G: eGFR grade above
• A: albuminuria category
  • A1: ACR <30 mg/g
  • A2: ACR 30-300 mg/g
  • A3: ACR >300 mg/g

• Cause
• GFR category, based on eGFR
• Albuminuria category, based on urine ACR

GFR grades (often called CKD stages)

Albuminuria grades

• C: cause
• G: eGFR grade above
• A: albuminuria category
  • A1: ACR <30 mg/g
  • A2: ACR 30-300 mg/g
  • A3: ACR >300 mg/g

• G3a A1: ACR <30 mg/g
• G3a A2: ACR 30-300 mg/g
• G3a A3: ACR >300 mg/g

Prognosis

• Progressive decline in kidney function and eventual kidney failure
• Hyperkalemia, anemia, acidosis, and CKD-mineral bone disease as CKD advances
• Major cardiovascular events, heart failure, stroke, and death

Essential assessment now

1. Repeat kidney function: creatinine/eGFR to establish trend and confirm chronicity.
2. Spot urine ACR: preferably first-morning sample; repeat to confirm persistent albuminuria.
3. Urinalysis and sediment: hematuria or active sediment may suggest another renal disease.
4. Check blood pressure, HbA1c, potassium, bicarbonate, complete blood count, lipids, calcium/phosphate, and medication list.
5. Assess diabetic retinopathy and neuropathy. Retinopathy supports diabetic kidney disease.
6. Renal ultrasound or nephrology review if there is atypical disease: rapid eGFR loss, hematuria, resistant hypertension, nephrotic syndrome, or no retinopathy with a short diabetes duration.

Management

1. Blood pressure and renoprotection

• Aim for BP <130/80 mmHg in most people with diabetes and CKD, individualized for tolerance. KDIGO uses a systolic target <120 mmHg when measured in a standardized manner.
• Use an ACE inhibitor or ARB at the maximum tolerated dose if hypertension with albuminuria is present. Do not combine an ACE inhibitor with an ARB.
• Check creatinine/eGFR and potassium about 2-4 weeks after starting or increasing an ACE inhibitor/ARB. A modest early eGFR decrease may occur; significant creatinine rise, symptomatic hypotension, or hyperkalemia needs review.

2. Diabetes treatment

• An SGLT2 inhibitor is usually indicated in CKD with type 2 diabetes at eGFR 45, unless contraindicated. It slows CKD progression and lowers cardiovascular and heart-failure risk even when its glucose-lowering effect is less at lower eGFR.
• Individualize HbA1c target, often around 7%, balancing benefits against hypoglycemia risk, age, comorbidity, and frailty.
• Consider a GLP-1 receptor agonist if further glucose lowering, weight reduction, or cardiovascular benefit is needed.
• Adjust doses of glucose-lowering drugs to eGFR. Avoid hypoglycemia-prone therapy where possible. Metformin may commonly be continued at eGFR 45 but should be reviewed and dose-adjusted as eGFR declines.

3. Persistent albuminuria despite ACE inhibitor/ARB

• If type 2 diabetes, albuminuria persists, eGFR is at least 25, and potassium is normal, consider finerenone, a nonsteroidal mineralocorticoid receptor antagonist. It requires potassium monitoring because it can cause hyperkalemia.

4. Cardiovascular risk reduction

• Use a moderate- or high-intensity statin unless contraindicated.
• Stop smoking, exercise as tolerated, manage body weight, and treat cardiovascular disease aggressively.
• Avoid NSAIDs such as ibuprofen, diclofenac, and naproxen unless specifically advised, particularly during dehydration or intercurrent illness.

5. Diet and monitoring

• Limit sodium to roughly <2 g sodium/day (about <5 g salt/day).
• Avoid high-protein diets. Usual CKD target is about 0.8 g protein/kg/day, adjusted by a clinician or renal dietitian.
• Avoid over-the-counter herbal remedies and contrast exposure unless necessary and planned.
• Monitor eGFR, potassium, and ACR at least every 3-6 months, more often if A3 albuminuria, medication changes, or declining renal function.

Referral