What is the best management strategy for a patient with impaired renal function, albuminuria, and elevated creatinine?

Management Approach for CKD with Creatinine 124 μmol/L, eGFR 57, and Urine ACR 20.8

For a patient with impaired renal function (eGFR 57 mL/min/1.73m²), mild albuminuria (ACR 20.8 mg/g), and elevated creatinine (124 μmol/L), the recommended first-line treatment is an angiotensin receptor blocker (ARB) or angiotensin-converting enzyme inhibitor (ACEi) to reduce albuminuria and slow CKD progression. 1

Classification and Risk Assessment

• The patient has Stage 3a CKD (eGFR between 45-59 mL/min/1.73m²) with mild albuminuria (ACR 20.8 mg/g, which falls in the 30-299 mg/g range) 1
• This combination of moderately reduced eGFR and albuminuria indicates increased risk for CKD progression and cardiovascular complications 1
• Based on the KDIGO monitoring frequency grid, this patient should be monitored approximately twice per year 1

Treatment Recommendations

First-Line Therapy

• Initiate an ACEi or ARB at the maximum tolerated dose indicated for blood pressure treatment 1
• ARBs such as losartan have demonstrated efficacy in reducing proteinuria and slowing progression of nephropathy in patients with type 2 diabetes 2
• Monitor serum creatinine and potassium levels within 2-4 weeks after initiating therapy and at least annually thereafter 1, 3
• Do not discontinue renin-angiotensin system blockade for mild to moderate increases in serum creatinine (≤30%) in the absence of volume depletion 1

Blood Pressure Management

• Target blood pressure should be ≤130/80 mmHg for patients with albuminuria 1
• If blood pressure remains above target despite maximum tolerated dose of ACEi/ARB, add a thiazide-like diuretic as second-line therapy 1, 4
• For resistant hypertension (not meeting targets on three medications including a diuretic), consider adding a mineralocorticoid receptor antagonist if eGFR is ≥25 mL/min/1.73m² 1

Additional Therapeutic Considerations

• For patients with type 2 diabetes and CKD, add an SGLT2 inhibitor if eGFR is ≥20 mL/min/1.73m² to reduce CKD progression and cardiovascular events 1
• If the patient has type 2 diabetes with BMI ≥30 kg/m², consider adding a GLP-1 receptor agonist for cardiovascular risk reduction 1
• Avoid combination of ACEi and ARB as this increases adverse effects without additional benefit 1, 3

Lifestyle Modifications

• Recommend dietary protein intake of 0.8 g/kg body weight per day 1
• Advise sodium restriction to less than 2 g per day 1, 5
• Implement other lifestyle interventions including achieving healthy BMI (20-25 kg/m²), smoking cessation, and regular exercise (30 minutes, 5 times weekly) 1
• For patients with diabetes, target hemoglobin A1c level of 7% 1

Monitoring Recommendations

• Monitor serum creatinine, eGFR, and potassium levels at least annually 1
• Assess urinary albumin excretion (UACR) annually to track progression 1
• For patients with albuminuria ≥300 mg/g, a reduction of 30% or greater in UACR is recommended to slow CKD progression 1
• Consider monitoring natriuretic peptides (NTproBNP or BNP) as biomarkers for heart failure risk 1

Referral Criteria

• Refer to a nephrologist if there is continuously increasing albuminuria and/or continuously decreasing eGFR 1
• Immediate referral is indicated if eGFR falls below 30 mL/min/1.73m² 1
• Promptly refer if there is uncertainty about the etiology of CKD 1

Common Pitfalls to Avoid

• Do not discontinue ACEi/ARB therapy for mild increases in creatinine (≤30%) as this is often an expected hemodynamic effect that correlates with long-term renoprotection 1, 6
• Avoid initiating ACEi/ARB in patients with severe volume depletion, as this can precipitate acute kidney injury 6
• Do not use dual RAS blockade (combination of ACEi and ARB) as this increases adverse effects without providing additional benefit 1, 3
• In advanced CKD (stages G4-G5), avoid DASH-type diets or potassium-rich salt substitutes due to hyperkalemia risk 5