From the Guidelines
For this 44-year-old male with hypertension, CKD stage 3b (GFR 43), elevated creatinine (1.93), and significant albuminuria (ACR 129), I recommend continuing lisinopril and optimizing blood pressure to a target of <130/80 mmHg, as recommended by the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1.
Treatment Approach
The patient's current treatment with lisinopril, an angiotensin-converting enzyme inhibitor (ACEi), is appropriate, as RAS inhibitors have been shown to slow the progression of kidney disease in persons with albuminuria and hypertension independent of their effects on blood pressure 1.
Additional Interventions
Additional interventions should include:
- Starting an SGLT2 inhibitor, such as empagliflozin 10mg daily or dapagliflozin 10mg daily, which have demonstrated kidney-protective effects by reducing hyperfiltration and albuminuria.
- A nephrology referral is warranted given his relatively young age with moderate CKD and significant albuminuria.
- Dietary modifications, including sodium restriction (<2g/day), moderate protein intake (0.8g/kg/day), and avoidance of nephrotoxins like NSAIDs.
- Screening for anemia, metabolic bone disease, and acidosis, which are common complications of CKD.
Monitoring and Follow-up
Regular monitoring of kidney function every 3-6 months is necessary to track disease progression and adjust therapy accordingly, as recommended by the 2020 KDIGO clinical practice guideline 1.
Workup
Additional workup should include:
- A complete metabolic panel
- Lipid profile
- Hemoglobin A1c
- Urinalysis with microscopy
- Renal ultrasound to assess kidney size and structure
- A 24-hour urine collection for protein and creatinine clearance This comprehensive approach addresses both the underlying kidney disease and its complications to slow progression and reduce cardiovascular risk.
From the FDA Drug Label
Dose in Patients with Renal Impairment No dose adjustment of lisinopril tablets is required in patients with creatinine clearance > 30 mL/min. In patients with creatinine clearance ≥ 10 mL/min and ≤ 30 mL/min, reduce the initial dose of lisinopril tablets to half of the usual recommended dose
- The patient has a Glomerular Filtration Rate (GFR) of 43, which is greater than 30 mL/min, so no dose adjustment of lisinopril is required based on renal impairment.
- The patient has a high albumin-to-creatinine ratio (ACR) of 129, which indicates kidney damage, but the drug label does not provide specific guidance on further workup and treatment for this condition.
- The patient's hypertension and CKD should be managed according to clinical guidelines, but the drug label does not provide specific recommendations for further workup and treatment. 2
From the Research
Further Workup
- The patient's high albumin-to-creatinine ratio (ACR) of 129 indicates significant albuminuria, which is a risk factor for progression of Chronic Kidney Disease (CKD) 3, 4.
- The patient's impaired renal function, with a creatinine level of 1.93 and a Glomerular Filtration Rate (GFR) of 43, suggests a need for careful monitoring and potential adjustment of medications 5, 6, 7.
- Further workup may include regular monitoring of blood pressure, kidney function, and urine albumin levels to assess the effectiveness of treatment and potential progression of CKD.
Treatment
- The patient is currently on Lisinopril, an angiotensin-converting enzyme (ACE) inhibitor, which is a common treatment for hypertension and CKD 5, 6, 7.
- However, the patient's high ACR and impaired renal function may indicate a need for additional or alternative therapies to slow disease progression, such as sodium-glucose cotransporter-2 (SGLT2) inhibitors, which have been shown to reduce the risk of CKD progression and cardiovascular events in patients with CKD 3, 4.
- The use of SGLT2 inhibitors, such as canagliflozin or dapagliflozin, may be considered in addition to or instead of Lisinopril, depending on the patient's individual needs and medical history 3, 4.
- Non-steroidal mineralocorticoid receptor antagonists (MRAs) may also be considered as an additional therapy to reduce albuminuria and slow CKD progression 4.