What is the treatment for an elevated urine protein to creatinine ratio (Impaired renal function) in a non-diabetic 87-year-old female?

From the Guidelines

The treatment for an elevated urine protein to creatinine ratio in a non-diabetic 87-year-old female typically involves ACE inhibitors or ARBs as first-line therapy, with a goal to reduce proteinuria and slow CKD progression, as recommended by the Kidney Disease: Improving Global Outcomes (KDIGO) guideline 1.

Key Considerations

• Medications such as lisinopril (starting at 2.5-5mg daily) or losartan (25-50mg daily) can be initiated at lower doses due to the patient's advanced age, with careful monitoring of blood pressure and kidney function.
• These medications reduce proteinuria by decreasing intraglomerular pressure and have renoprotective effects beyond blood pressure control.
• Dietary sodium restriction to 2-3g daily is also recommended, as it can help reduce proteinuria and slow CKD progression 1.

Monitoring and Follow-up

• Regular monitoring should include serum creatinine, potassium, and urine protein levels every 2-4 weeks initially, then every 3-6 months once stable.
• Blood pressure should be maintained below 140/90 mmHg, with more conservative targets (such as <150/90 mmHg) sometimes appropriate in very elderly patients to avoid orthostatic hypotension, as suggested by the KDIGO guideline 1.

Additional Considerations

• If proteinuria persists despite these measures, referral to a nephrologist is warranted to evaluate for underlying causes such as glomerulonephritis or amyloidosis, which may require specific treatments.
• Avoiding nephrotoxic medications like NSAIDs and ensuring adequate hydration are also important supportive measures.
• The European Society of Hypertension (ESH) and the European Society of Cardiology (ESC) guidelines also recommend strict blood pressure control and reduction of proteinuria to slow CKD progression, although the optimal blood pressure target may vary depending on the individual patient's characteristics 1.

From the FDA Drug Label

The RENAAL study was a randomized, placebo-controlled, double-blind, multicenter study conducted worldwide in 1513 patients with type 2 diabetes with nephropathy (defined as serum creatinine 1.3 to 3.0 mg/dL in females or males ≤60 kg and 1.5 to 3. 0 mg/dL in males >60 kg and proteinuria [urinary albumin to creatinine ratio ≥300 mg/g]). Treatment with losartan resulted in a 16% risk reduction in this endpoint (see Figure 4 and Table 4) Treatment with losartan also reduced the occurrence of sustained doubling of serum creatinine by 25% and ESRD by 29% as separate endpoints, but had no effect on overall mortality (see Table 4). Compared with placebo, losartan significantly reduced proteinuria by an average of 34%, an effect that was evident within 3 months of starting therapy, and significantly reduced the rate of decline in glomerular filtration rate during the study by 13%, as measured by the reciprocal of the serum creatinine concentration

The patient in question is a non-diabetic 87-year-old female with an elevated urine protein to creatinine ratio of 13.94 mg/mmol. Losartan may be considered for treatment, as it has been shown to reduce proteinuria and slow the progression of renal disease in patients with nephropathy 2. However, the patient's non-diabetic status and age may require careful consideration and monitoring.

• The primary goal of treatment should be to slow the progression of renal disease and reduce proteinuria.
• Losartan may be initiated at a dose of 50 mg once daily, with titration to 100 mg once daily if necessary to achieve the desired effect.
• Close monitoring of the patient's renal function, blood pressure, and proteinuria is essential to assess the effectiveness of treatment and adjust the dose as needed.

From the Research

Treatment Options for Elevated Urine Protein to Creatinine Ratio

The treatment for an elevated urine protein to creatinine ratio in a non-diabetic 87-year-old female involves several options, including:

• Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) to decrease urinary protein excretion and slow the progression of renal disease 3, 4
• Combination therapy with an ACE inhibitor and an ARB, which has been shown to be safe and effective in reducing proteinuria in patients with chronic proteinuric renal disease 3
• Nondihydropyridine calcium channel blockers (non-DHP CCBs) as an alternative or additional treatment option for patients with proteinuria, particularly those with diabetic kidney disease 5

Considerations for Treatment

When considering treatment options, the following factors should be taken into account:

• The patient's age and renal function, as well as the presence of any comorbidities or contraindications to certain medications
• The potential benefits and risks of each treatment option, including the risk of hyperkalemia or changes in serum creatinine levels 4
• The patient's blood pressure and the need for antihypertensive therapy, as well as the potential for ACE inhibitors or ARBs to provide renoprotective effects beyond their blood pressure-lowering effects 6

Real-World Use of Treatment Options

Studies have shown that ACE inhibitors and ARBs are not always used as recommended in clinical practice, particularly in older patients or those with more advanced renal disease 7

• A cross-sectional study found that only 28% of hypertensive patients with chronic kidney disease and proteinuria were prescribed ACE inhibitors or ARBs, despite guideline recommendations 7
• The prescription rate was lower in younger patients and those with earlier stages of renal disease, highlighting the need for increased awareness and adherence to guideline recommendations 7