What is the treatment for albuminuria?

Treatment for Albuminuria

Renin-angiotensin system inhibitors (ACE inhibitors or ARBs) are the first-line treatment for albuminuria, regardless of blood pressure status, with the goal of reducing progression to kidney failure and cardiovascular events. 1, 2

Treatment Algorithm Based on Albuminuria Severity

For Macroalbuminuria (≥300 mg/g)

• ACE inhibitors or ARBs are strongly recommended for patients with macroalbuminuria (severely increased albuminuria), regardless of diabetes status or blood pressure levels 1
• In patients with type 2 diabetes and macroalbuminuria, ARBs like losartan have demonstrated a 28.6% risk reduction in progression to end-stage renal disease 2
• Target dose should be titrated to maximum approved dose for hypertension in the absence of side effects 1
• Monitor for side effects including hyperkalemia, acute kidney injury, and hypotension 1

For Microalbuminuria (30-300 mg/g)

• ACE inhibitors or ARBs are suggested for patients with microalbuminuria (moderately increased albuminuria) 1
• For patients with diabetes and microalbuminuria, ACE inhibitors or ARBs are strongly recommended 1
• In patients with type 1 diabetes, ACE inhibitors have shown greater evidence of benefit, while in type 2 diabetes, ARBs have more extensive supporting data 1

Monitoring and Follow-up

• Check serum creatinine and potassium within 1 week of starting medication or following dose escalation 1
• Monitor urine albumin/creatinine ratio every 3-6 months to assess treatment response 3
• A reduction in albuminuria of ≥30% is considered a positive response to therapy 3
• Temporarily suspend medication during acute illness, before IV contrast administration, or prior to major surgery 1

Blood Pressure Targets

• Target blood pressure should be <130/80 mmHg in patients with albuminuria 1, 3
• The 2021 KDIGO guidelines recommend a systolic blood pressure target of less than 120 mm Hg for all patients with CKD, regardless of albuminuria status 1
• Many patients will require combination therapy to achieve blood pressure targets 1

Important Cautions and Considerations

• Dual blockade with both ACE inhibitors and ARBs is not recommended due to increased risk of adverse events, particularly impaired kidney function and hyperkalemia 1
• ACE inhibitors and ARBs are contraindicated during pregnancy due to potential fetal harm 1
• In patients with sickle cell disease and albuminuria, ACE inhibitors or ARBs should be started at a lower dose if GFR is <45 mL/min/1.73 m² 1
• Albuminuria reduction is a valid treatment target as it correlates with long-term renal and cardiovascular protection 4, 5

Special Populations

• In children and adolescents with type 2 diabetes, screening for microalbuminuria should begin at diagnosis and be repeated annually 1
• In patients with sickle cell disease and albuminuria, ACE inhibitors or ARBs are suggested with appropriate monitoring 1
• In normotensive patients with diabetes and albuminuria, the target dose of ACE inhibitors or ARBs is not well established, but titration to maximum approved dose is suggested in the absence of side effects 1

Rationale for Treatment

• Albuminuria is a marker of vascular inflammation and endothelial dysfunction that predicts both kidney disease progression and cardiovascular events 4, 6
• The degree of albuminuria reduction with treatment correlates with the degree of renal and cardiovascular protection 5
• Higher baseline albuminuria is associated with greater absolute and relative risk reduction from blood pressure-lowering drugs 7