From the Guidelines
Black individuals with proteinuria should be promptly evaluated and managed with ACE inhibitors or ARBs, such as lisinopril 10-40mg daily or losartan 50-100mg daily, to reduce proteinuria and slow kidney disease progression, as evidenced by the KDIGO practice guideline 1. The management of Black individuals with proteinuria requires a comprehensive approach to address the higher prevalence and faster progression of kidney disease in this population.
Key Management Strategies
- Initial management includes ACE inhibitors or ARBs to reduce proteinuria and slow kidney disease progression, with a goal of controlling blood pressure to <130/80 mmHg, as recommended by the JNC 7 report 1 and the KDIGO practice guideline 1.
- Lifestyle modifications are essential, including:
- Sodium restriction (<2g/day)
- Moderate protein intake (0.8g/kg/day)
- Smoking cessation
- Regular exercise
- Regular monitoring of kidney function, proteinuria, and electrolytes is necessary every 3-6 months.
- Black patients may need earlier nephrology referral due to faster progression of kidney disease, particularly with APOL1 genetic variants that increase risk.
Additional Considerations
- Combination therapy with both ACE inhibitors and ARBs is not recommended due to increased adverse effects, as noted in the KDIGO practice guideline 1.
- Diuretics may be added if needed for blood pressure control or edema.
- The AASK study found that achieving a mean BP of 128/78 mm Hg did not provide additional renal protection compared to a mean BP of 141/85 mm Hg in African American individuals with hypertensive CKD 1.
- The MDRD study demonstrated that individuals with proteinuria had slower rates of progression to ESRD if their SBP values were 130 mm Hg 1.
- The KDIGO practice guideline recommends long-term ACEi or ARB treatment when proteinuria is ≥1 g/day, with uptitration of the drug depending on BP 1.
From the FDA Drug Label
Table 5: Efficacy Outcomes within Demographic Subgroups No of Patients Primary Composite Endpoint ESRD Losartan Event Rate % Placebo Event Rate % Hazard Ratio (95% CI) Losartan Event Rate % Placebo Event Rate % Hazard Ratio (95% CI) ... Race Black 230 40.0 39.0 0.98 (0.65,1.50) 17.6 21.0 0.83 (0.46,1.52)
The effect of losartan on Blacks with proteinuria is not significantly different from placebo, with a hazard ratio of 0.98 (0.65,1.50) for the primary composite endpoint and 0.83 (0.46,1.52) for ESRD 2.
- Key points:
- No significant difference in primary composite endpoint
- No significant difference in ESRD
- Losartan may not have a significant benefit in Blacks with proteinuria compared to placebo.
From the Research
Proteinuria in Blacks
- Proteinuria is a risk marker for the progression of chronic kidney disease (CKD) 3
- Treatment with an angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker (ACEi/ARB) is beneficial in patients with proteinuria 3, 4
ACEi/ARB Treatment
- ACEi/ARB treatment is associated with a lower rate of starting renal replacement therapy (RRT) in patients with proteinuria 3
- However, many patients with proteinuria are not taking maximal ACEi/ARB doses, which may limit the effectiveness of treatment 5, 6
- Barriers to ACEi/ARB use in proteinuric CKD include past acute kidney injury, hyperkalemia, advanced CKD, and lack of nephrology care 6
Comparison of ACE Inhibitors and ARBs
- There is no difference in efficacy between ARBs and ACE inhibitors with regard to blood pressure and outcomes of all-cause mortality, cardiovascular mortality, myocardial infarction, heart failure, stroke, and end-stage renal disease 7
- However, ACE inhibitors are associated with a higher risk of adverse events, such as cough and angioedema, compared to ARBs 7