What is the recommended management for a 62-year-old male with hypertension (HTN), impaired renal function, and a urine creatinine ratio (UCR) of 87.2 mg/mmol?

Management of Hypertension with Impaired Renal Function

For a 62-year-old male with hypertension, eGFR of 62 ml/min/1.73m², creatinine of 109 μmol/L, and urine creatinine ratio of 87.2 mg/mmol, treatment should begin with an angiotensin receptor blocker (ARB) or ACE inhibitor due to the presence of significant proteinuria, along with lifestyle modifications targeting blood pressure control and renoprotection. 1

Assessment of Renal Status

• The patient has Stage 2 chronic kidney disease (CKD) based on eGFR of 62 ml/min/1.73m² (60-89 ml/min/1.73m² range defines Stage 2) 2
• The urine creatinine ratio of 87.2 mg/mmol indicates significant proteinuria, which is a marker of kidney damage and glomerular filtration barrier derangement 2, 1
• This combination of reduced eGFR and proteinuria indicates a greater risk of cardiovascular and renal events than either abnormality alone 1
• Elevated serum creatinine and proteinuria are strong predictors of future cardiovascular events and mortality 2, 3

Pharmacological Management

First-Line Treatment

• Start with an ACE inhibitor or ARB (such as losartan) as first-line therapy due to the presence of significant proteinuria 1, 4
• Losartan is specifically indicated for treatment of diabetic nephropathy with elevated serum creatinine and proteinuria, and has shown benefits in reducing proteinuria by an average of 34% 4
• ARBs/ACEIs have been shown to reduce the rate of progression of renal disease as measured by doubling of serum creatinine or progression to end-stage renal disease 4

Additional Medications

• If blood pressure remains ≥150/90 mmHg, consider initial treatment with two antihypertensive medications to more effectively achieve blood pressure control 1
• Add a thiazide-like diuretic (chlorthalidone or indapamide preferred) if additional medication is needed 1
• A calcium channel blocker (dihydropyridine type) can be added as a third agent if needed 1
• Avoid the combination of ACE inhibitor and ARB together as this increases risk of hyperkalemia and acute kidney injury without additional cardiovascular benefit 1

Blood Pressure Targets

• Target blood pressure should be <130/80 mmHg if tolerated, but not <120 mmHg systolic 1
• Regular monitoring of blood pressure is essential to ensure targets are being met 1

Monitoring

• Monitor serum creatinine and potassium within 7-14 days after initiation of ACE inhibitor or ARB therapy 1
• Continue monitoring at least annually, with more frequent monitoring if there are changes in medication or clinical status 1
• A slight increase (up to 20%) in serum creatinine may occur when antihypertensive therapy with RAS blockers is initiated but should not be taken as a sign of progressive renal deterioration 1

Lifestyle Modifications

• Recommend dietary sodium restriction to enhance the effectiveness of antihypertensive medications 1, 5
• Weight loss if indicated (BMI >25) 1
• Regular physical activity (at least 150 minutes per week of moderate-intensity activity) 1
• Limit alcohol consumption 1

Management of Resistant Hypertension

• If blood pressure remains uncontrolled despite three medications including a diuretic, consider adding a mineralocorticoid receptor antagonist (spironolactone) at low dose 1, 5
• Monitor potassium closely when using spironolactone, especially in the setting of reduced renal function 1
• If spironolactone is not tolerated, consider eplerenone, beta-blockers, or alpha-blockers 1

Special Considerations

• Avoid NSAIDs as they can worsen renal function and interfere with the effectiveness of antihypertensive medications 5
• If renal function deteriorates significantly (eGFR <30 ml/min/1.73m²), consider nephrology referral 5
• The presence of both reduced eGFR and proteinuria indicates a higher risk profile requiring more aggressive management 1

By following this management approach, the goal is to control blood pressure, reduce proteinuria, and slow the progression of renal disease, ultimately reducing cardiovascular and renal morbidity and mortality in this patient.